Semin Plast Surg 2017; 31(04): 177-188
DOI: 10.1055/s-0037-1607275
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

Jacob S. Feldman
,
Soroush Farnoosh
,
Robert M. Kellman
,
Sherard A. Tatum III
Further Information

Publication History

Publication Date:
25 October 2017 (online)

Abstract

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

 
  • References

  • 1 CDC. Traumatic brain injury& Concussion. 2017; Available at: http://www.cdc.gov/traumaticbraininjury/ . Accessed March 28, 2017
  • 2 Michael L, Mandana B. Retrospective study of skull base fracture: a study of incidents, complications, management, and outcome overview from trauma-one-level institute over 5 years. J Neurol Surg B Skull Base 2013; 74 (01) 239
  • 3 Grant JR, Rhee JS, Pintar FA, Yoganandan N. Modeling mechanisms of skull base injury for drivers in motor vehicle collisions. Otolaryngol Head Neck Surg 2007; 137 (02) 195-200
  • 4 McElhaney JH, Hopper Jr RH, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma 1995; 12 (04) 669-678
  • 5 Slupchynskyj OS, Berkower AS, Byrne DW, Cayten CG. Association of skull base and facial fractures. Laryngoscope 1992; 102 (11) 1247-1250
  • 6 Sakas DEB, Beale DJ, Ameen AA. , et al. Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. J Neurosurg 1998; 88 (03) 471-477
  • 7 Madhusudan G, Sharma RK, Khandelwal N, Tewari MK. Nomenclature of frontobasal trauma: a new clinicoradiographic classification. Plast Reconstr Surg 2006; 117 (07) 2382-2388
  • 8 Kang HM, Kim MG, Boo SH. , et al. Comparison of the clinical relevance of traditional and new classification systems of temporal bone fractures. Eur Arch Otorhinolaryngol 2012; 269 (08) 1893-1899
  • 9 Winkler-Schwartz A, Correa JA, Marcoux J. Clival fractures in a level I trauma center. J Neurosurg 2015; 122 (01) 227-235
  • 10 Menkü A, Koç RK, Tucer B, Durak AC, Akdemir H. Clivus fractures: clinical presentations and courses. Neurosurg Rev 2004; 27 (03) 194-198
  • 11 Pretto Flores L, De Almeida CS, Casulari LA. Positive predictive values of selected clinical signs associated with skull base fractures. J Neurosurg Sci 2000; 44 (02) 77-82 ; discussion 82–83
  • 12 Guyer RA, Turner JH. Delayed presentation of traumatic cerebrospinal fluid rhinorrhea: case report and literature review. Allergy Rhinol (Providence) 2015; 6 (03) 188-190
  • 13 Meurman OH, Irjala K, Suonpää J, Laurent B. A new method for the identification of cerebrospinal fluid leakage. Acta Otolaryngol 1979; 87 (3–4): 366-369
  • 14 Oberascher G, Arrer E. Efficiency of various methods of identifying cerebrospinal fluid in oto- and rhinorrhea. ORL J Otorhinolaryngol Relat Spec 1986; 48 (06) 320-325
  • 15 Meco C, Oberascher G, Arrer E, Moser G, Albegger K. Beta-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003; 129 (05) 508-517
  • 16 West OC, Mirvis SE, Shanmuganathan K. Transsphenoid basilar skull fracture: CT patterns. Radiology 1993; 188 (02) 329-338
  • 17 Proskynitopoulos PJ, Stippler M, Kasper EM. Post-traumatic anosmia in patients with mild traumatic brain injury (mTBI): a systematic and illustrated review. Surg Neurol Int 2016; 7 (Suppl. 10) S263-S275
  • 18 Worthington JP, Snape L. Horner's syndrome secondary to a basilar skull fracture after maxillofacial trauma. J Oral Maxillofac Surg 1998; 56 (08) 996-1000
  • 19 Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma 2003; 54 (05) 1026-1034
  • 20 Lehn AC, Lettieri J, Grimley R. A case of bilateral lower cranial nerve palsies after base of skull trauma with complex management issues: case report and review of the literature. Neurologist 2012; 18 (03) 152-154
  • 21 Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med 2015; 22 (04) 390-398
  • 22 Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000; 343 (02) 100-105
  • 23 Smits M, Dippel DW, de Haan GG. , et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA 2005; 294 (12) 1519-1525
  • 24 Stiell IG, Clement CM, Rowe BH. , et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005; 294 (12) 1511-1518
  • 25 Sheth S, Branstetter IV BF, Escott EJ. Appearance of normal cranial nerves on steady-state free precession MR images. Radiographics 2009; 29 (04) 1045-1055
  • 26 Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World J Surg 2001; 25 (08) 1062-1066
  • 27 Stone JA, Castillo M, Neelon B, Mukherji SK. Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography. AJNR Am J Neuroradiol 1999; 20 (04) 706-712
  • 28 Sillers MJ, Morgan CE, el Gammal T. Magnetic resonance cisternography and thin coronal computerized tomography in the evaluation of cerebrospinal fluid rhinorrhea. Am J Rhinol 1997; 11 (05) 387-392
  • 29 Keerl R, Weber RK, Draf W, Wienke A, Schaefer SD. Use of sodium fluorescein solution for detection of cerebrospinal fluid fistulas: an analysis of 420 administrations and reported complications in Europe and the United States. Laryngoscope 2004; 114 (02) 266-272
  • 30 Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004; 62 (06) 676-684
  • 31 Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997; 18 (02) 188-197
  • 32 Prosser JD, Vender JR, Solares CA. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin North Am 2011; 44 (04) 857-873 , vii
  • 33 Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2011; (08) CD004884
  • 34 Batra PS. Endoscopic evaluation and treatment of CSF leaks. Bailey's Head and Neck Surgery–Otolaryngology. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014. (p. 1 online resource, 2 volumes)
  • 35 Citardi M, Fakhri S. Cerebrospinal fluid rhinorrhea. Cummings Otolaryngology: Head and Neck Surgery. Philadelphia, PA: Elsevier Health Sciences; 2015. (p. 1 online resource)
  • 36 Reyes C, Mason E, Solares CA. Panorama of reconstruction of skull base defects: from traditional open to endonasal endoscopic approaches, from free grafts to microvascular flaps. Int Arch Otorhinolaryngol 2014; 18 (Suppl. 02) S179-S186
  • 37 Jones V, Virgin F, Riley K, Woodworth BA. Changing paradigms in frontal sinus cerebrospinal fluid leak repair. Int Forum Allergy Rhinol 2012; 2 (03) 227-232
  • 38 Soudry E, Turner JH, Nayak JV, Hwang PH. Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 2014; 150 (05) 730-738
  • 39 Zuniga MG, Turner JH, Chandra RK. Updates in anterior skull base reconstruction. Curr Opin Otolaryngol Head Neck Surg 2016; 24 (01) 75-82
  • 40 Fishpool SJ, Amato-Watkins A, Hayhurst C. Free middle turbinate mucosal graft reconstruction after primary endoscopic endonasal pituitary surgery. Eur Arch Otorhinolaryngol 2017; 274 (02) 837-844
  • 41 Hadad G, Bassagasteguy L, Carrau RL. , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
  • 42 Hoffmann TK, El Hindy N, Müller OM. , et al. Vascularised local and free flaps in anterior skull base reconstruction. Eur Arch Otorhinolaryngol 2013; 270 (03) 899-907
  • 43 Eldaly A, Magdy EA, Nour YA, Gaafar AH. Temporalis myofascial flap for primary cranial base reconstruction after tumor resection. Skull Base 2008; 18 (04) 253-263
  • 44 McCall TD, Fults DW, Schmidt RH. Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections-report of 3 cases. Surg Neurol 2008; 70 (01) 92-96 ; discussion 96–97
  • 45 Patel A, Groppo E. Management of temporal bone trauma. Craniomaxillofac Trauma Reconstr 2010; 3 (02) 105-113
  • 46 Kveton JF. Obliteration of mastoid and middle ear for severe trauma to the temporal bone. Laryngoscope 1987; 97 (12) 1385-1387
  • 47 Mack KF, Kempf HG, Lenarz T. Patients with trauma-induced deafness–rehabilitation using a cochlear implant [Article in German]. Wien Med Wochenschr 1997; 147 (10) 249-251
  • 48 Ulug T, Arif Ulubil S. Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures. Am J Otolaryngol 2005; 26 (04) 230-238
  • 49 do Nascimento Remigio AF, Salles AG, de Faria JC, Ferreira MC. Comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA at the 1: 3 conversion ratio for the treatment of asymmetry after long-term facial paralysis. Plast Reconstr Surg 2015; 135 (01) 239-249
  • 50 May M. Facial reanimation after skull base trauma. Am J Otol 1985; (Suppl): 62-67
  • 51 Flint PW. , et al. Cummings Otolaryngology: Head and Neck Surgery. London: Elsevier Health Sciences; 2015. (p. 1 online resource)
  • 52 Sekhar LN, Schramm VL. Tumors of the Cranial base: Diagnosis and Treatment. Mount Kisco, New York, NY: Futura Publishers; 1987
  • 53 Snyderman CH, Janecka IP, Sekhar LN, Sen CN, Eibling DE. Anterior cranial base reconstruction: role of galeal and pericranial flaps. Laryngoscope 1990; 100 (06) 607-614
  • 54 Raveh J, Vuillemin T, Sutter F. Subcranial management of 395 combined frontobasal-midface fractures. Arch Otolaryngol Head Neck Surg 1988; 114 (10) 1114-1122
  • 55 Raveh J, Laedrach K, Speiser M. , et al. The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 1993; 119 (04) 385-393
  • 56 Kellman RM, Marentette L. The transglabellar/subcranial approach to the anterior skull base: a review of 72 cases. Arch Otolaryngol Head Neck Surg 2001; 127 (06) 687-690
  • 57 Kellman RM, Goyal P, Rodziewicz GS. The transglabellar subcranial approach for nasal dermoids with intracranial extension. Laryngoscope 2004; 114 (08) 1368-1372
  • 58 Figueiredo EG, Deshmukh P, Nakaji P. , et al. The minipterional craniotomy: technical description and anatomic assessment. Neurosurgery 2007; 61 (05) (Suppl. 02) 256-264 ; discussion 264–265
  • 59 Yaşargil MG, Teddy PJ, Roth P. Selective amygdalo-hippocampectomy. Operative anatomy and surgical technique. Adv Tech Stand Neurosurg 1985; 12: 93-123
  • 60 Yaşargil MG, Krayenbühl N, Roth P, Hsu SP, Yaşargil DC. The selective amygdalohippocampectomy for intractable temporal limbic seizures. J Neurosurg 2010; 112 (01) 168-185
  • 61 Altay T, Couldwell WT. The frontotemporal (pterional) approach: an historical perspective. Neurosurgery 2012; 71 (02) 481-491 ; discussion 491–492
  • 62 Winn HR, Youmans JR. Youmans Neurological Surgery. London: Elsevier Health Sciences; 2011. (p. 1 online resource)
  • 63 Yaşargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg 1987; 67 (03) 463-466
  • 64 Figueiredo EG, Teixeira MJ, Spetzler RF, Preul MC. Clinical and surgical experience with the minipterional craniotomy. Neurosurgery 2014; 75 (03) E324-E325
  • 65 Jane JA, Park TS, Pobereskin LH, Winn HR, Butler AB. The supraorbital approach: technical note. Neurosurgery 1982; 11 (04) 537-542
  • 66 Haines SJ, Marentette LJ, Wirtschafter JD. Extended fronto-orbital approaches to the anterior cranial base: variations on a theme. Skull Base Surg 1992; 2 (03) 134-141
  • 67 Kabil MS, Shahinian HK. Application of the supraorbital endoscopic approach to tumors of the anterior cranial base. J Craniofac Surg 2005; 16 (06) 1070-1074 ; discussion 1075
  • 68 Cheong EC, Chen CT, Chen YR. Endoscopic management of orbital floor fractures. Facial Plast Surg 2009; 25 (01) 8-16
  • 69 Chen HI, Bohman LE, Emery L. , et al. Lateral transorbital endoscopic access to the hippocampus, amygdala, and entorhinal cortex: initial clinical experience. ORL J Otorhinolaryngol Relat Spec 2015; 77 (06) 321-332
  • 70 Abuzayed B, Tanriover N, Gazioglu N, Eraslan BS, Akar Z. Endoscopic endonasal approach to the orbital apex and medial orbital wall: anatomic study and clinical applications. J Craniofac Surg 2009; 20 (05) 1594-1600
  • 71 Chhabra N, Wu AW, Fay A, Metson R. Endoscopic resection of orbital hemangiomas. Int Forum Allergy Rhinol 2014; 4 (03) 251-255
  • 72 Stokken J, Gumber D, Antisdel J, Sindwani R. Endoscopic surgery of the orbital apex: Outcomes and emerging techniques. Laryngoscope 2016; 126 (01) 20-24
  • 73 Antisdel JL, Gumber D, Holmes J, Sindwani R. Management of sinonasal complications after endoscopic orbital decompression for Graves' orbitopathy. Laryngoscope 2013; 123 (09) 2094-2098
  • 74 Moe KS, Bergeron CM, Ellenbogen RG. Transorbital neuroendoscopic surgery. Neurosurgery 2010; 67 (3, Suppl Operative) ons16-ons28
  • 75 Moe KS, Kim LJ, Bergeron CM. Transorbital endoscopic repair of cerebrospinal fluid leaks. Laryngoscope 2011; 121 (01) 13-30
  • 76 Ciporen JN, Moe KS, Ramanathan D. , et al. Multiportal endoscopic approaches to the central skull base: a cadaveric study. World Neurosurg 2010; 73 (06) 705-712
  • 77 Bly RA, Ramakrishna R, Ferreira M, Moe KS. Lateral transorbital neuroendoscopic approach to the lateral cavernous sinus. J Neurol Surg B Skull Base 2014; 75 (01) 11-17