A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures.

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Frontobasal Fractures.

Frontobasal fractures occur in up to 24% of head injuries and often require a multidisciplinary approach. Besides the common bone fractures, the complex anatomy can cause damage to the sense of vision and smell. Further possibly lethal complications such as cerebrospinal fluid leak followed by meningitis or internal carotid bleeding can follow. Diagnostic and treatment options are reviewed with a focus on the endoscopic endonasal approach.

Maxillofacial Fractures: Midface and Internal Orbit-Part II: Principles and Surgical Treatment.

Current clinical assessment and imaging techniques were described in part 1, and this article presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments enabled limited surgical approaches by standardization of osteosynthesis principles regarding three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intra- and postoperative imaging. Resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension to reduce ptosis effects in the cheeks and nasolabial area and to achieve facial aesthetics similar to those prior to the injury.

The anterior interhemispheric approach: a safe and effective approach to anterior skull base lesions.

BACKGROUND: Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base. METHODS: We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery. We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n = 43), ethmoidal dural arteriovenous fistula (dAVF) ( n = 6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n = 12). Patient records were evaluated concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications. RESULTS: The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n = 2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n = 1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %). CONCLUSIONS: The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons.

Late complication of the frontobasal trauma.

The injuries of the frontobasal region are always a great challenge to a surgeon, especially the management of bone defects of the frontal region. The authors present a patient with late, 33-year postaccident complication, which had been surgically treated, and whose frontal bone defect had been reconstructed with methyl methacrylate. Clinical examination and computed tomography confirmed signs of previous operation and presence of an infection and alloplastic material. Specific for this case was challenge to manage chronic infection and reestablish integrity of the skull in the frontal region. Out of a variety of autogenous or alloplastic materials, and considering the extent of bone defect and previous episodes of treatment aimed at aesthetic and functional results with good prognosis, we opted for reconstruction of the frontal region defect with combined titanium mesh impregnated with the hydroxyapatite cement.

An orbital roof and anterior skull base fracture: case report.

Blow-out fractures usually involve the orbit in the floor or in the medial wall. Anyway, if the roof of the orbit is thin and direct compressive or buckling forces impact the orbit the fracture can involve the upper roof. We describe the case of a blow-out fracture of the orbital roof with enophtalmus and cerebrospinal fluid leak from lacero-contusive subciliar wound

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature.

BACKGROUND: Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures. METHODS: PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes. RESULTS: We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery. CONCLUSIONS: ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

Prophylactic antibiotics and anticonvulsants in neurosurgery.

The prophylactic administration of antibiotics to prevent infection and the prophylactic administration of anticonvulsants to prevent first seizure episodes are common practice in neurosurgery. If prophylactic medication therapy is not indicated, the patient not only incurs the discomfort and the inconvenience resulting from drug treatment but is also unnecessarily exposed to adverse drug reactions, and incurs extra costs. The main situations in which prophylactic anticonvulsants and antibiotics are used are described and those situations we found controversial in the literature and lack further investigation are identified: anticonvulsants for preventing seizures in patients with chronic subdural hematomas, antiepileptic drugs for preventing seizures in those suffering from brain tumors, antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, and antibiotic prophylaxis for the surgical introduction of intracranial ventricular shunts.In the following we present systematic reviews of the literature in accordance with the standard protocol of The Cochrane Collaboration to evaluate the effectiveness of the use of these prophylactic medications in the situations mentioned. Our goal was to efficiently integrate valid information and provide a basis for rational decision-making.

[Diagnosis and treatment of injuries to the frontal skull base]. / Diagnostik und Therapie von Verletzungen der Frontobasis.

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.

Basilar skull fracture: outcome of acute care without antibiotic prophylaxis in a Nigerian neurosurgical unit.

AIM: A prospective observational study of the in-hospital outcome of the management of BSF without antibiotic prophylaxis in a Nigerian neurosurgical unit. MATERIAL AND METHODS: All cases of HI with clinical diagnosis of BSF over an 8-month period were reviewed. Their demographic, clinical, and in-hospital outcome parameters were analysed. We also compared some clinical and outcome characteristics between this study group and a contemporary cohort of patients in our unit with Head Injury but without CSF leak RESULTS: There were 47 cases. The CSF leak was from the nostrils in 18 (38.3%), the ears in 16 (34.04%), and both ears and nostrils in 12 (25.53%). The cause of injury was road accidents in 91%, and the severity of the Head Injury was mild, moderate and severe respectively in 42.55, 25.53 and 31.91%. Meningitis occurred in 2 patients (4.25%); in-hospital outcome was good in 68.1% and poor in 31.9% and this was significantly (p < 0.05) affected primarily by the severity of the brain injuries. These in-hospital outcome rates and their determinants were similar to those in our unit's contemporary cohort of Head Injury without BSF. CONCLUSION: Management of traumatic BSF without antibiotic prophylaxis in a developing country setting has not been accompanied with an increased rate of unfavourable outcome.

Entrapment of the basilar artery within a clivus fracture: Case report and literature review.

A review of the literature revealed that basilar artery (BA) entrapment is a very rare (17 cases published) and severe pathological condition, which often leads to death. We report the case of a 72-year-old man who presented with a longitudinal clivus fracture associated with a basilar artery entrapment. This entrapment was responsible for a basilar artery dissection, which led to an ischemic stroke in the pons. The patient was managed with medical treatment, mainly to avoid a progression towards an ischemic stroke. It consisted of heparin therapy followed by antiplatelet therapy, which finally resulted in a successful outcome. In BA entrapment most of the patients who had a favorable outcome received antithrombotic therapy. This suggests that antithrombotic therapy might be useful in the first line treatment of post-traumatic BA entrapment.

Indirect gunshot wound to the head.

BACKGROUND: An Afghani man presented to a U.S. military facility in Afghanistan with a 3-month history of clear fluid from his left naris and frequent sinusitis. Eleven years earlier, he had been struck in the forehead by an object falling from the sky. MATERIALS AND METHODS: Neurologic examination revealed decreased sensation in V1 and V2 on the left side. Imaging revealed a large bullet lodged in the left maxillary sinus. FINDINGS: The bullet was removed via sublabial incision and opening of the anterior bony wall of the maxillary sinus. CONCLUSIONS: In Afghanistan, indirect gunshot wounds to the head are not uncommon because of the constant war conditions since the invasion by the former Soviet Union in 1979 and the tradition of firing rounds into the air during cultural celebrations.

Pneumococcal polysaccharide vaccination administered early after neurotrauma or neurosurgery.

OBJECTIVES: Pneumococcal vaccination is recommended to lower the risk of posttraumatic meningitis, and early vaccination may be of importance. After both trauma and central nervous system injury, immune-suppression may occur, which could affect T-cell function and the response to T-cell dependent vaccines. We therefore aimed to investigate the response to early vaccination with a T-cell independent pneumococcal polysaccharide vaccine (PPSV). METHODS: Thirty-three patients with basilar skull fracture and 23 patients undergoing transsphenoidal pituitary gland surgery were vaccinated with PPSV within 10days after neurotrauma or neurosurgery. Twenty-nine neurosurgical patients vaccinated ⩾3weeks after neurotrauma or neurosurgery served as controls. Serotype-specific anti-polysaccharide binding IgG antibody levels to serotypes 4, 6B, 9V, 14, 18C, 19F and 23F were determined by enzyme immunoassay. RESULTS: The vaccination was safe and a highly significant antibody response was found against all serotypes in all groups (p<0.001 for each of the serotypes). There were no differences between groups or in the group by time interaction in any of the serotypes. After early and late vaccination, protective levels were found in >80% for serotypes 9V, 14, 18C, 19F and 23F and in 70% and 50% for serotypes 6B and 4, respectively. CONCLUSION: Patients vaccinated with PPSV within 10days after neurotrauma or neurosurgery respond similarly to those vaccinated after ⩾3weeks, indicating that PPSV can be administered early after neurotrauma or neurosurgery. CLINICAL TRIALS REGISTRATION: NCT02806284.

Basilar Artery Herniation into the Sphenoid Sinus Secondary to Traumatic Skull Base Fractures: Case Report and Review of the Literature.

BACKGROUND: Traumatic clival fractures occur with less than 0.6% frequency and can be associated with significant neurovascular injuries. The most serious of these injuries is to the basilar artery in which the artery is dissected or is fully occluded, resulting in infarction of the brainstem and cerebellum. Among early reports of these injuries, postmortem autopsy showed entrapment, or incarceration, of the basilar artery at the clival fracture site. A literature search revealed 11 cases of entrapment of the basilar artery within a clival fracture. CASE DESCRIPTION: This report describes a 59-year-old man after a motor vehicle crash with computed tomography showing a basilar artery herniation through a sphenoid sinus fracture. The patient subsequently developed brainstem and cerebellar infarcts. CONCLUSIONS: Basilar artery incarceration and herniation through the sphenoid sinus is rare. Such an injury portends a poor prognosis. We discuss the relevant clinical imaging and review the literature.

The effect of direction of force to the craniofacial skeleton on the severity of brain injury in patients with a fronto-basal fracture.

The skull base is uniquely positioned to absorb force imparted to the craniofacial skeleton, thereby reducing brain injury. Less well understood is the effect of the direction of force imparted to the craniofacial skeleton on the severity of brain injury. Eighty-one patients from two UK major trauma centres who sustained a fronto-basal fracture were divided into two groups: those struck with predominantly anterior force and those by predominantly lateral force. The first recorded Glasgow Coma Score (GCS), requirement for intubation, and requirement for decompressive craniectomy were used as markers of the severity of brain injury. An average GCS of 5 was found in the lateral group and 14 in the anterior group; this difference was statistically significant (P<0.001). There was an increased need for both intubation and decompressive craniectomy in the lateral group compared to the anterior group (absolute risk difference 46.6% and 15.8%, respectively). These results suggest that the skeletal anatomy of the fronto-basal region influences the severity of head injury. The delicate lattice-like structure in the central anterior cranial fossa can act as a crumple zone, absorbing force. Conversely in the lateral aspect of the anterior cranial fossa, there is a lack of collapsible interface, resulting in an increased energy transfer to the brain.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair.

BACKGROUND: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. METHODS: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. RESULTS: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. CONCLUSIONS: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Skull base trauma: diagnosis and management.

The singular anatomical relationship of the base of the skull is responsible for the particular problems that may arise after injury. Extensive dural laceration and severe neurovascular damage may accompany skull base injuries. Trauma to the anterior skull base is frequently related to the paranasal sinuses, and trauma to the middle and the posterior skull base usually affects the petrous bone. Injury to the anterior fossa including the paranasal sinuses may produce CSF leakage, damage the olfactory nerves, optic nerves, and orbita contents. Fractures may affect the carotid canal, injure the internal carotid artery and result in carotid-cavernous fistula. Trauma to the petrous bone may cause facial palsy and deafness, and CSF leakage with otorrhoea or paradoxal rhinoliquorrhoea. Trauma to the posterior fossa may lacerate the major venous sinuses, and affect the cranio-cervical stability. Each one of these injuries will need a particular strategy. Decision making for management as a whole must consider all aspects, including the fact that these injuries frequently involve polytraumatized patients. Decisions regarding the timing of surgery and the sequence of the surgical procedures must be made with great care. Modern surgical techniques and recent technologies including functional preservation of the olfactory nerves in frontobasal trauma, visual evoked potentials, assisted optic nerve decompression, facial nerve reconstruction, interventional technique for intravascular repair of vascular injuries, and recent developments in cochlea implants and brain stem implants, all contributed significantly to improve outcome and enhance the quality of life of patients. This article reviews basic principles of management of skull base trauma stressing the role of these advanced techniques.

Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients.

OBJECT: The author's personal series included 148 patients who sustained traumatic frontobasal injuries and were treated between 1986 and 1999. Included in this study are 74 of 148 patients with acute injuries and complex frontobasal lesions involving the frontal sinus, the cribriform/ethmoid roof complex, one or both orbital roofs, and the planum sphenoidale. METHODS: Surgery was delayed for up to 4 weeks postinjury in most patients (67 cases), whereas 17 with space-occupying hematomas and perforating injuries required early surgery. In 30 patients additional surgery was required to treat maxillofacial fractures, which was performed as a one-stage procedure together with the neurosurgical operation. The author performed a standard bifrontal craniotomy in which an intradural or combined intradural-extradural approach was used in all cases. Four patients developed ascending meningitis in the preoperative period. As a result of surgical treatment one patient died, another two patients suffered from permanent defects, and three suffered from transitory neurological worsening. In two patients recurrence of a cerebrospinal fluid fistula occurred within a 3-month period posttreatment but was successfully obliterated during reoperation. In the author's experience the intradural approach is comparable in terms of the morbidity, mortality, and success rates with extracranial approaches; additionally the intradural approach provides full visualization of the intracranial lesion. Useful olfactory nerve function can only be preserved if both olfactory nerves are left intact and not crushed during initial injury; this occurred in only five patients in this series. CONCLUSIONS: If possible, surgical treatment of more complex lesions should be delayed until the 2nd or 3rd week following traumatic injury. With antibiotic prophylaxis the risk that ascending meningitis will occur prior to surgery is low. If the patient is systemically stable and brain swelling has resolved, even extensive one-stage neurosurgical/maxillofacial procedures are well tolerated.