Hemorrhage in Frontal Skull Base Fractures

The ethmoid artery and branches of the maxillary artery are involved in extensive ethmoid fractures. If there is no spontaneous obliteration, there may be heavy nasal and pharyngeal bleeding, which will require intervention.

Massive bleeding which spreads through the fractured medial orbital wall into the posterior orbit may cause exophthalmus and gradual compression of the optic nerve and the ophthalmic artery.

The result is a hemorrhagic compression syndrome with progressive loss of vision. Similar complications can be expected if hemorrhaging from the ethmoid arteries is inappropriately controlled, obliterating the apparent nasal hemorrhaging, yet not sufficiently compressing the arterial stump.

Fractures of the middle cranial fossa mostly result in hemorrhaging from the ear or into the tympanic cavity (hematotympanon) with the result of possible deafness.

6.3.1.1  Emphysema

Subcutaneous emphysema indicates fractures of the walls of the paranasal sinuses. This is a regular finding in ethmoid fractures and can be an indication of skull base involvement.

Orbital Emphysema

Orbital emphysema (intraorbital emphysema) suggests a frontal skull base or ethmoid fracture with mucosal tearing, or an orbital floor fracture. If air escapes from the nose and paranasal sinuses, via the orbit into the lid system, a lid emphysema results, which can be recognized by so-called emphysema crackling and is partly associated with simultaneous conjunctival emphysema.

6.2  Midface Injuries (Clinical Signs)

Whilst clinically examining the midface one should seek mobility of the maxillary block with possible dislocation (dorso-caudal displacement/disturbed occlusion), an open bite and bony steps along the periorbital rim,

the zygomatic bone, the nasal skeleton and intraorally in the upper vestibule along the zygomatico-maxillary buttress (Lew and Sinn 1991; Keith 1992; Schwenzer and Ehrenfeld 2002).

Direct signs of midface fractures are

•Abnormal motility

•Dislocation

•Abnormal occlusion

•Evidence of crepitation and abnormal resonance

6.2.1  Central Midface Fractures without Abnormal Occlusion (NOE Fractures)

In central midface fractures, depression of the nasomaxillary struts, fractures of the medial orbital wall and naso-ethmoidal structures may lead to an increase in distance between the medial angles of the eyes (telecanthus). Avulsion of the canthal ligaments, increasing interpupillary distance (hypertelorismus) and injuries to the nasolacrimal duct are possible.

Simultaneous fractures of the frontal skull base with dural lacerations may result in rhinoliquorrhea and anosmia caused by avulsion of the olfactory filaments (Holt 1986).

6.2.2  Central Midface Fractures with Abnormal Occlusion (Le Fort I and II)

The most important sign is the abnormal mobility of the fractured midfacial block. Maxillary displacement regularly results in malocclusion. Dorsal and caudal displacement of the midface results in an anterior open bite as well as flattening and lengthening of the midface.

Uneven surfaces can be palpated on the anterior bony aperture of the nose, the facial wall of the maxillary sinus and particularly on the zygomatico-alveolar buttress and in the region of the infraorbital margin. In the rare case of ruptured retromaxillary vessels (maxillary artery and vein) life-threatening hemorrhage may occur (Spiessl et al. 1976).

Sensory disorders (hyp-/anaesthesia) occur regularly in the region supplied by the infraorbital nerve as

a consequence of infraorbital foramen or infraorbital canal involvement.

6.2.3  Centrolateral Midface Fractures

with Abnormal Occlusion (Le Fort III)

The clinical symptoms of Le Fort II and III fractures are similar. The midface is abnormally mobile, flattened, and displaced in a dorsal and caudal direction. Malocclusion is a regular feature. Uneven surfaces in the region of the lateral orbit and root of the nose are often present, but not always evident due to swelling. Skull base involvement with liquorrhea as a result of dural injury is not uncommon. Additional dural injuries in polytraumatized patients lying in a supine position are initially not clinically obvious, as the liquor runs directly into the nasopharynx and, at best, the patient`s frequent swallowing becomes conspicuous.

6.2.4  Lateral Midface Fractures

A monocular hematoma and depression in the zygomatic region are often clinically impressive. Depending on fracture type, there are often palpable steps alongside the lateral orbit, at the infraorbital margin and at the zygomatico-alveolar buttress.

In strongly dislocated fractures and comminuted fractures, the facial prominence is flattened. Extreme zygomatic displacent results in reduced mouth opening. In case of extensive dislocation of the orbital floor, there may be an additional difference of the pupillary axis and disturbed eye motility resulting from ocular muscle entrapment as well as an enophthalmus (Spiessl and Schroll 1972).

As the infraorbital foramen and the infraorbital canal are almost constantly involved in zygomatic fractures, there are frequent sensory defects of the infraorbital nerve (Spiessl and Schroll 1972; Schwenzer and Ehrenfeld 2002) (Fig. 6.24).