Endoscopic Endonasal Reconstruction of Extensive Anterior Skull Base Defect from Gunshot Wound

Introduction: Ballistic injuries involving the skull base can be challenging to manage. Significant bone and soft tissue loss in addition to tissue ischemia, infection, and necrosis can complicate reconstruction. Thorough debridement with transfer of vascularized tissue is an important aspect of management. We describe a case of a patient who presented with a gunshot wound (GSW) to the face causing extensive damage to the anterior skull base and surrounding structures.

Method: Case report.

Results: A 34-year-old male presented with a GSW to the right face. On arrival, he had a Glasgow coma scale score of 6. The bullet had entered through the right nasal bridge, traversing the right nasal cavity and orbit, and shattering the anterior skull base to penetrate the frontal and parietal lobes. Computed tomography demonstrated acute intracranial hemorrhage in addition to middle cerebral artery dissection, right globe rupture, and destruction of the cribriform and orbital roof with herniation of brain tissue through the anterior skull base defect ([Fig. 1]). After emergent bilateral decompressive frontotemporal craniectomy, endoscopic endonasal debridement and reconstruction of the skull base were performed six days later. Intraoperatively, necrotic brain matter was seen protruding from the right nostril ([Fig. 2]). Necrotic brain tissue mixed with bony partitions in the nasal cavity was debrided, leaving a defect of the entire right anterior skull base including the orbital roof. An abdominal fat graft was used to fill the large intracranial dead space, and duraplasty using collagen matrix was performed. A nasoseptal flap was then draped over the ethmoid roof and the medial orbit. The patient made an extensive recovery, sustaining mildly diminished cognitive capacity and left hemiparesis. The patient returned 5 months after surgery, and the reconstruction was found to be fully healed on endoscopy ([Fig. 3]).

Conclusion: This case demonstrates the utility of the endoscopic endonasal approach to debride and reconstruct an extensive anterior skull base defect resulting from GSW.

Fig. 1 Computed tomography image demonstrating destruction of the right anterior skull base.

Fig. 2 Operative image of necrotic brain matter protruding from the right nostril.

Fig. 3 Endoscopic image of right nasal cavity 5 months after surgery showing fully healed reconstruction with pedicled nasoseptal flap.

No conflict of interest has been declared by the author(s).