Raveh and Vuillemin (1988) found recurrent liquorrheainonly1.9%of374patientstreatedforcranio­ -facial fractures. The number of preoperative cerebrospinal fluid (CSF) rhinorrheas of patients operated on within the first 24 h, however, was unknown (Probst and Tomaschett 1990).

Sealing of dural lacerations has become more successful with the introduction of fibrin glue and the use of fascia-lata grafts (Raveh et al. 1984, 1988; Probst and Tomaschett 1990; Lädrach 2007) found postoperative CSF leakage in 2.3% of craniofacial traumas with skull base and dural injuries.

In our patient group, recurrent liquorrhea occurred in 2.8% of all operated patients. In the remaining patients, neither immediate postoperative nor late liquorrhea was found.

This proves that our surgical technique, which includes wide exposure, multi-layered dural and skull base repair and primary bony reconstruction provides reliable and stable results.

Our treatment concept for recurrent liquorrhea initially consists of waiting for 2-3 weeks with simultaneous antibiotics, 30° head inclination and lumbal drainage. If no spontaneous occlusion of the fistula occurs, localization of the leakage is performed with the use of CT/ Jotrolan - CT/MRI/Liquor Scintigraphy/Na-Fluorescein liquor marking.

dead space, an efficient separation between paranasal sinuses and intracranial space and the protection and support of neural structures and bone grafts (Eufinger et al. 1999; Stepnick 1999).

Flap techniques for skull base reconstruction

Local flaps

 Temporal flap

 Pericranial flap

 Galea flap

Free flaps (fascio-cutaneous)

 Lateral upper arm flap

 Anterior lateral thigh flap

 Rectus abdominis flap

 Scapula/parascapular flap

 Radialis forearm flap

 Latissimus dorsi flap

 DIEP flap

The selection of free flaps is based upon:

•Approach and possibility of integration

•Necessary volume

•Possible anastomoses

•Possibility of contouring

Control of the vitality of the inserted microvascular flaps and skin paddles is important, but difficult. In extreme situations angiographies or endoscopic controls may be necessary (Fig. 13.5).

Treatment concept for recurrent liquorrhea:

•Wait 2-3 weeks/antibiotics/30° head elevation/ lumbar drainage

•Clarify fistula localization

•(Coronal CT/Jotrolan-­CT/MRI/liquor scintigraphy/Na fluorescein)

•Frontal skull base revision

Depending on the localization of recurrent liqor fistulas, either the transfrontal or the endonasal approach is performed. Occasionally a combined procedure is necessary.

In extreme cases with delayed liquorrhea and extensive bone loss, the skull base is either reconstructed with bone grafts or titanium mesh. The reconstructed skull base has to be covered with local flaps (pericranial flaps) or, alternatively, occluded by integrating microsurgically anatomized free flaps (fascio-cutane- ous flaps) (Seeger 1983; Bootz and Gawlowski 1995; Schmelzeisen and Schliephake 1998).

The advantages of microvascular free flaps are a secure watertight dural closure, the obliteration of any

13.4  Hematoma: Central Edema

In 2% of our patients, an epidural hematoma developed in the postoperative phase, which had to be evacuated according to the progression evident on computed tomography (CT). Meticulous intraoperative hemostasis, watertight dural occlusion, tack-up sutures and a subgaleatic suction drainage are important prophylactic measures.

Irreparable cerebral damage from central edema (2%) and severe cranio-cerebral trauma with extensive hemorrhage were responsible for the postoperative mortality in 4% of our patients.

13.5  Subdural Hygroma

Subdural effusions are an accumulation of fluid between the dura and arachnoid membrane. They occur as a result of cranio-cerebral injury and, rarely, as a postoperative complication of craniofacial injuries. Their treatment

a

b1

b2

Fig. 13.5  Microvascular free flaps for coverage a traumatic liquor fistula 17 years after severe craniofacial trauma with extensive loss of bone in the anterior skull base. (a) Skull base exposure with large skull base defect (arrow) after bilateral craniotomy and frontal osteotomy. (b) Insertion and anastomosis of a microvascular DIEP flap before and after reintegration of the frontal segment and coverage of the lacerated and scarred dura with a parieto-occipital pericranial flap

corresponds with that of subdural hematomas with recraniotomy and hygroma removal as well as tack-up sutures and placement of an epidural suction drainage (Schmidek and Sweet 1988) (Fig. 13.6).

13.6  Frontal Sinus: Complications

If there is remaining mucosa following cranialization of the frontal sinus, this may lead to formation of mucoceles, pyoceles, and epidural abscesses (Lädrach 2007: 2%). We observed mucocele formation at a frequency of 3.3% in the region of the frontal sinus (Neidhardt 2002).

These patients were re-craniotomized, the mucocele removed and the residual dead space filled either with a pericranial flap or cancellous bone grafts (Baker et al. 2003) (Figs. 13.7, 13.8 and 13.9).

13.7  Functional Neurological Deficits

Nearly 7% of our patients had persisting anesthesia of the supraorbital nerve. In 3%, permanent weakness of the frontal branch of the facial nerve was found, and in 4% there was a traumatic injury of the optic nerve with loss of vision. In 2% of the patients, posttraumatic epilepsy occurred as a result of the primary trauma. Olfactory dysfunction (hypor anosmia) as a result of the surgical intervention (transfrontal-intracranial) was found in 8% (Neidhardt 2002).

13.8  Meningitis

Meningitis following skull base revision is always a sign of persisting, mostly occult liquorrhea. Every suspicion of liquorrhea must, therefore, be examined until finally proven otherwise. There was no occurrence of meningitis in our patient group, whereas Lädrach (2007) observed postoperative meningitis in 2.1%.

Fig. 13.4  Frontal osteomyelitis. Reconstruction of the craniofrontal region with titanium mesh (a1–a3). Depressed cranio- naso-orbito-maxillary fracture. (b1–b2) Primary reconstruction of the frontocranial and naso-ethmoidal region. (c1) Chronic infection with cutaneous fistula formation (5 weeks after primary­

reconstruction). (c2) Revision with removal of all infected bone fragments and the osteosynthesis material and reconstruction with titanium mesh. (d1–d3) Postoperative X-ray control. (e) Integrated titanium mesh 12 months postoperatively. No signs of infection