Skull Base / Facial Fractures (general)

Facts

This page is to be used as a general guide to the non-operative skull-base fracture occurring in numerous locations (frontal sinus, orbits, ethmoids, sphenoid, clivus), all of which have similar expectant management with monitoring for CSF leak.
 
For specific skull base fractures which are often operative, see also:
Tegmen Defects (Tympani and Mastoideum)
Temporal Bone Fracture

HPI

universal ROS
  • positional HA (general CSF leak ROS)
  • bulbar symptoms (clival fractures)

PHYSICAL EXAM

universal neuro exam
  • ask about positional HA
  • raccoon eyes (periorbital ecchmoses)
  • Battle’s sign: postauricular eccymoses
(LEFT): Racoon eyes (RIGHT) Battle’s sign
(LEFT): Racoon eyes (RIGHT) Battle’s sign
  • close attention to cranial nerve exam (including lower)
  • provoke CSF leak from nares / ears
    • option 1: chin to chest: if feasible with the rest of polytruamas (i.e. don’t need to be flat for TLS precautions)
    • option 2: log-roll
      • patients will often be in cervical or TLS spine precautions, this is not a reason to not test. Can still roll over patient on their side/belly and have their nose be looking down.

IMAGING

CT Max-face
CT Temporal bone
Specific fracture types
  • frontal sinus fx: evaluate whether anything beyond anterior wall is injured

A/P

  • Keep red top tubes at bedside to collect CSF
  • generally non-operative, but neurosurgery should follow for at least 24-48 hours for CSF leak watch
  • If patient leaks,
    • consider placing LD for 3-5 days while patient heals
    • if patient continues to leak despite LD, consider doing a cisternogram for pre-operative planning to evaluate the source of leak (see below).
  • ENT should be consulted to scope the patient and evaluate for signs of CSF pooling in nasal cavity
  • consider pituitary labs (including Na+) if any proximity to sella
  • Imaging: as above
    • CT venogram if any fractures near dural sinuses → assess for traumatic DVST
    • CTA head and neck to evaluate for any arterial injury associated with adjacent fractures and also should be done universally for screening given risk of concomitant blunt cerebrovascular injury unrelated to fractures
Facial fractures
  • Counsel: risks of unrepaired facial fractures: infection, mucocele, sinusitis
    • Indications for repair of anterior frontal sinus fractures:
      • cosmetic deformity
      • if injuries past just the anterior wall

Specific Fractures

Le-fort fractures

Clivus fractures

  • transverse, longitudinal, oblique
    • transverse:
      • tend to affect anterior circulation
    • longitudinal:
      • tend to affect vertebro-basilar circulation, sometimes leading to entrapment
      • worst prognosis
CT angiography of the head in sagittal (left), axial (center), coronal (right) planes demonstrating transverse clivus fracture involving bilateral carotid canals.
CT angiography of the head in sagittal (left), axial (center), coronal (right) planes demonstrating transverse clivus fracture involving bilateral carotid canals.

Planum Sphenoid Defects

Young male with a 20-foot fall from tree with an extensive right facial fracture complex including R orbital roof and floor, R cribriform plate, R lamina papyracea, R zygomatic arch, sphenoid wing, lateral wall of maxillary sinus was found to have a CSF leak originating from the planum fracture as proven on a cisternogram demonstrating dense contrast accumulation in R sphenoid sinus.
Young male with a 20-foot fall from tree with an extensive right facial fracture complex including R orbital roof and floor, R cribriform plate, R lamina papyracea, R zygomatic arch, sphenoid wing, lateral wall of maxillary sinus was found to have a CSF leak originating from the planum fracture as proven on a cisternogram demonstrating dense contrast accumulation in R sphenoid sinus.