8.7  Endonasal-Endoscopical Approach

wounds and should only be used in selected cases with marginally displaced fractures of the anterior wall of the frontal sinus.

Risks associated with the transfacial transethmoi- dal-subdural approach:

•Injury to the orbital walls, orbital hematoma

•Increased orbital volume, enophthalmus

•Risk of injuring the optical nerve

•Iatrogenic dural injuries

•Damage to the olfactory fibers

Extensive debridement of the ethmoid by multifragmentation of the medial osseous orbital wall may lead to additional instability of the orbit. This is particularly relevant for the so-called orbital-key area (sino-­ethmoidal angle). This region is particularly important in stabilizing the orbit. If debridement of the osseous orbital frame takes place in this region and the bony stability is reduced, orbital tissue prolapse into the paranasal sinuses may result (Ernst et al. 2004).

A significant disadvantage of the transfacial-transeth- moidal approach is that simultaneous cerebral injuries cannot be adequately treated.

Efficient fistula closure is particularly problematic in regions where the intact and strongly adherent dura cannot easily be released from the bone (ethmoid roof, cribriform plate). The subbasal extradural plasty is less reliable than the intracranial one (Probst 1986; Lange et al. 1995). Bilateral and/or multiple lesions treated extracranially are more difficult to treat because of the poor view. Additionally, the entire orbital roof cannot be inspected or reduced.

8.7  Endonasal-Endoscopical Approach

The endoscopically based nasal surgery for treating base fractures in the anterior cranial fossa is exclusively endonasal (Draf 1978, 1981, 1992; Wigand 1989; Stammberger 1991; Thumfarth et al. 1998; Gjuric et al. 1996; Pia und Aluffi 1997; Burns et al. 1996; Schick et al. 1997, 1998).

The endonasal technique causes the least trauma, but is only reliable in circumscribed skull base fractures with liquor fistulas in the fronto-ethmoidal region.

8.7.1  Ethmoid Roof Fractures:

Surgical Principles

Isolated frontobasal fractures of the posterior and midethmoidal sections can be treated from the endonasalextradural approach. The definitive treatment of ethmoid roof fractures follows that of accompanying midfacial fractures, which should be repositioned and stabilized beforehand.

After the ethmoid cells have been opened, the defect in the skull base is exposed using the diamond burr under endoscopic and microscopic control, so providing a full view of the dural injuries. As the dura is quite adherent in this region, it may be necessary to repress the brain with gauzes. Defect exposure in the region of the crista galli may be difficult. Injured and prolapsed brain tissue is repositioned using protective gauzes; hematomas are evacuated.

Reconstruction is always compromised by increased cerebral pressure. Decreasing cerebral pressure by draining the liquor and supporting the reconstruction with a tamponade minimizes this danger (Ernst et al. 2004).

8.7.2  Sphenoid Fractures

Defects in the region of the posterior ethmoid roof and particularly isolated defects of the sphenoid sinus are treated endonasally (Dietrich et al. 1993; Pia and Aluffi 1997; Landreneau et al. 1998; Schroth et al. 1998). The transnasal surgical closure of sphenoid defects has a success rate of about 90% (Stoll 1993; Schick et al. 1996; Delank et al. 1998). The essential drainage of the paranasal sinuses can be peformed simultaneously during this intervention.

8.8  Surgical Approaches/

Own Statistics

In 70% of our own patients with craniofacial fractures we chose the transfrontal-transcranial approach, in 20% the transfrontal-subcranial and in 10% the unilateral transfacial-frontoorbital approach.

In 23% the transfrontal-intradural approach was necessary due to extensive cerebral injuries (Neidhardt

2002). (The number of subcranial approaches increases if osteotomies with resection of a fronto-cranio-nasal- segment are added to the subcranial approaches).

Distribution of surgical approaches in craniofacial fractures (Neidhardt 2002)

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