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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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Section 4 Trauma244
A
C
Figs. 18.6A to D: Traumatic cerebrospinal uid rhinorrhea. (A and B) CT cisternography.
Bony defect at the right ethmoid roof with contrast column extending from intracranial
compartment to the ethmoid sinus. Pneumocephalus (star) seen in brain. Fracture of lateral
orbital wall on right side; (C and D) Contrast MR cisternography shows contrast extending
from intracranial compartment to the ethmoid sinus and nasal cavity.
B
D
Iatrogenic Trauma (Figs. 18.7A and B)
■ Secondary to neurosurgical or otolaryngological procedures along skull
base, mostly endoscopic and endonasal procedures. It can also occur
following craniotomy.
■ Common sites—cribriform plates along vertical insertion of middle
turbinate, frontal sinuses and regions of variant anatomy including
pneumatization of skull base.
■ Accounts for 16% of all traumatic CSF rhinorrhea cases.
■ Present within rst 2 weeks following the operative procedure.
A B
Figs. 18.7A and B: Iatrogenic leak. (A) Coronal; and (B) Sagittal MR images in a 27-year-old
male who underwent transsphenoidal skull base surgery 2 months back shows a defect in
the roof of the sphenoid sinus with cerebrospinal uid and brain herniation consistent with
encephalocele.
■ Usually resolve spontaneously with conservative measures.
■ Presence of packs or hemorrhage secondary to the procedure may
hamper the interpretation of CT cisternography.
Secondary Leaks
■ It refers to the leaks of nontraumatic etiology but with a denite
pathologic cause.
■ Etiologies include erosion by tumors, mucoceles, postradiation changes,
osteonecrosis, congenital (encephaloceles, persistent canals through
skull base) (Figs. 18.8A and B).
■ Its identication is important for surgical management.
245Chapter 18 Imaging of Cerebrospinal Fluid Leaks
A B
Figs. 18.8A and B: Congenital frontoethmoidal encephalocele. (A) Coronal; and
(B) Sagittal reformatted CT images. A large defect is seen in anterior skull base through
which brain parenchyma is herniating into the ethmoid sinuses.
Section 4 Trauma246
Spontaneous Leaks
■ Cerebrospinal uid leaks occurring without any identiable cause such
as trauma, surgery, underlying lesion or congenital abnormality.
■ It may represent 4–40% of all CSF leaks.
■ Most often these patients present with clinical features of raised
intracranial pressure and are found to have idiopathic intracranial
hypertension (IIH) (Figs. 18.9A and B).Imaging required to rule out any
cause of raised intracranial pressure and to evaluate for features of IIH
(given in Table 18.1).
■ Empty sella, widening of optic sheath with tortuosity, scleral attening
at posterior aspect, scalloping of inner calvarial table, widening of skull
base foramina, meningoceles, low-lying cerebellar tonsils with inferiorly
displaced brainstem and cerebellum. MR venography may reveal
stenosis of transverse sinuses.
■ Most common sites of leak are cribriform plate or ethmoid roof.
Table 18.1: Radiological signs of idiopathic intracranial hypertension.
• Empty sella
• Widening of optic sheath with tortuosity
• Scleral attening at posterior aspect
• Scalloping of inner calvarial table
• Widening of skull base foramina
• Meningoceles
• Low-lying cerebellar tonsils with inferiorly displaced brainstem and cerebellum
• Stenosis of transverse sinuses on magnetic resonance venography
A B
Figs. 18.9A and B: Intracranial idiopathic hypertension in a 45-year-old female patient
with spontaneous cerebrospinal uid (CSF) rhinorrhea. Coronal MR cisternography CISS
image (A) shows a uid signal intensity column in the right ethmoid sinus suggestive of CSF
leak. (B) Empty sella seen on the sagittal image.
■ Management requires surgery for the defect as well as medication to
decrease intracranial pressure so as to prevent future recurrences.
PROTOCOL FOR EVALUATION FLOWCHART 18.1
■ Most leaks usually resolve either spontaneously or conservative measures
including lumbar drain placement by 7–10 days. Imaging is required if
persistent leak present.
■ Plain high-resolution computed tomography (HRCT) skull base is the
rst imaging modality. If shows a clear defect in skull base at a single site
which is correlating clinically with side of leak, then no more investigation
is required. e surgery can be planned based on CT.
■ If the HRCT shows multiple defects or if the site of defect is equivocal,
then further evaluation is done based on how strong is the suspicion for
Flowchart 18.1: Algorithm for workup of cerebrospinal uid (CSF) rhinorrhea.
247Chapter 18 Imaging of Cerebrospinal Fluid Leaks
(HRCT: high-resolution computed tomography; FDA: Food and Drug Administration)
Section 4 Trauma248
CSF rhinorrhea. If it is a conrmed CSF leak clinically and biochemically,
then CT cisternography can be done as the next investigation. If there is a
doubt whether it is CSF rhinorrhea or not, then plain MR cisternography
can be done as the next investigation being noninvasive and nonradiating.
■ If plain HRCT ndings reveal a possibility of an encephalocele or a tumor
or congenital defect, then MR cisternography should be done after it with
or without intravenous contrast.
■ MR cisternography with intrathecal contrast is reserved as a problemsolving tool (o-label use).
■ Contrast CT and MR cisternography are particularly useful in the setting
of multiple defects and in recurrence following surgery.
BIBLIOGRAPHY
1. Algin O, Hakyemez, B, Gokalp G, et al. e contribution of 3D-CISS and contrastenhanced MR cisternography in detecting cerebrospinal uid leak in patients
with rhinorrhea. Br J Radiol. 2010;83:225-32.
2. Baugnon KL, Hudgins PA. Skull base fractures and their complications. Neuroimaging Clin N Am. 2014;24(3):439-65.
3. Connor SE. Imaging of skull-base cephalocoeles and cerebrospinal uid leaks.
Clin Radiol. 2010;65(10):832-41.
4. Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal uid
leaks in adults. Radiology. 2008;248(3):725-36.
5. Reddy M, Baugnon K. Imaging of cerebrospinal uid rhinorrhea and otorrhea.
Radiol Clin North Am. 2017;55(1):167-87.
6. Selcuk H, Albayram S, Ozer H, et al. Intrathecal gadolinium-enhanced MR
cisternography in the evaluation of CSF leakage. AJNR Am J Neuroradiol. 2010;
31(1):71-5.
7. Sherif C1, Di Ieva A, Gibson D, et al. A management algorithm for cerebrospinal
uid leak associated with anterior skull base fractures: detailed clinical and
radiological follow-up. Neurosurg Rev. 2012;35:227-38.
8. Wang EW1, Vandergrift WA, Schlosser RJ. Spontaneous CSF leaks. Otolaryngol
Clin North Am. 2011;44(4):845-56.
19
CHAPTER
Sinonasal Trauma and
Cerebrospinal Fluid Rhinorrhea:
Surgical Aspects
Kapil Sikka, Alok Thakkar
• Causes
• Evaluation and Approach to Patient
with Facial Trauma
– Soft Tissue Injuries of Face
– Bony Sinonasal Injuries
▪ Upper-third Face Fractures
▪ Middle-third Face Fractures
• General Principles in Managing
Facial Fractures
CAUSES
■ Face is a commonly injured part of body. e common causes being
road trac accidents, interpersonal violence, injuries at workplace and
home (falls and machine related injuries). Some places also witness
serious injuries related to animal bites.
■ Seat belts, and airbags, though have played signicant protective role,
facial injuries are common after road trac accidents involving 50%
of survivors.
■ Management is challenging because of close proximity and possible
direct impact on vital structures like upper airway, larynx, trachea,
carotid artery, etc. is chapter will primarily focus on the diagnosis and
management of sinonasal injuries with fractures and cerebrospinal uid
(CSF) rhinorrhea.
• Cerebrospinal Fluid Rhinorrhea
– Symptoms
– Signs
– Investigations
– Management
EVALUATION AND APPROACH TO PATIENT WITH FACIAL TRAUMA
■ All major injury patients require general systemic evaluation as per
advanced trauma life support (ATLS) protocols.
■ Airway, spine, thoracic, cardiac and major abdominal injuries can be life
threatening and take precedence.
Section 4 Trauma250
■ Careful history regarding mode of injury and exact recapitulation of
events can provide a useful clue to severity and also aid in management.
■ General examination for evaluation of systemic injuries and
corresponding referrals is important.
■ Local examination should focus on evaluation of skin and soft tissue
lacerations over face. Antibiotic and tetanus prophylaxis needs to be
individualized on case-to-case basis. Adequate wound assessment at
times requires local or general anesthesia. orough wound irrigation
with saline or an antiseptic aids in assessment and also to identify and
remove debris and foreign bodies.
■ Bony eminences and contours should be palpated for deformity, step-os
and mobility. ese include the skull, orbit, zygoma, maxilla, mandible
and palate.
■ Some critical injuries to the eyelid, nasolacrimal duct, facial nerve,
parotid duct are often missed and fare badly, if not dealt immediately.
■ Eye and ear examination should be performed, and any abnormality
should be assessed by an expert. Blood in ear canal, abnormal
conjunctival congestion, hematoma behind the ear, etc. can be evidences
of more serious skull base fracture.
■ Disruption of canalicular apparatus should be suspected in eyelid
injuries. Vision and ocular mobility should be grossly assessed and
documented.
■ Imaging may be ordered in case there is suspicion of deep injury or
undetected fractures. Foreign bodies like glass or metallic pieces may be
identied with imaging while some like wood may be missed. Very careful
evidence of head injury should be obtained. Overt CSF rhinorrhea, nasal
and ear bleed, vomiting, visual blurring, diplopia or inequality of pupil
size should warrant prompt radiology to identify skull fractures and
underlying brain injury.
Soft Tissue Injuries of Face
■ Soft tissue injuries can be abrasions, lacerations or avulsions.
■ Basic concepts of cosmetic and functional repair need to be applied
while evaluating and repairing these wounds. Concepts of tattooing,
wound contraction and scarring should be kept in mind.
■ Appropriate suture material and/or adhesive is paramount for
appropriate results.
■ Special consideration and expert consultation should be sought in
injuries involving critical areas like eyelids, lips, salivary glands and facial
nerve.
■ Ears and nose soft tissue injuries should be handled with respect and
care because of high risk of deformities due to cartilage loss and risk of
perichondritis and deformity.
Bony Sinonasal Injuries
Face is arbitrarily divided into upper third formed by frontal bones, middle
third by maxilla, ethmoids and zygoma, and lower third by mandible.
Upper-third Face Fractures
■ ey may be only anterior wall fractures where they are mostly of cosmetic
concern or involves posterior wall also where intracranial injuries must
be investigated and treated.
Middle-third Face Fractures
■ Middle-third fractures involve the maxilla, zygoma and the ethmoids.
Due consideration to orbit, dental occlusion and skull base needs to be
given for adequate management. Conventionally, middle third fractures
are classied by Le Fort fracture classication (Chapter 17).
■ Lower-third (mandible fractures): Mostly due consideration needs
to be given to anatomic region of fracture and whether the bone is
dentulous or edentulous. Dental occlusion is important consideration
for management.
GENERAL PRINCIPLES IN MANAGING FACIAL FRACTURES
■ Computed tomography scan is the single most important diagnostic
modality for evaluating the extent of fractures and their management.
Plain radiographs, though frequently employed for simple nasal
fractures, are unnecessary.
■ As already highlighted, the life-threatening injuries of brain, abdomen
and thorax take precedence over fracture xations. General principles of
management are same as mentioned in soft tissue injuries.
■ Incisions may be customized to allow the access to the area and facilitate
elevation and xation of fracture fragments. ese include:
• Bicoronal incision for frontal and upper third fractures
• Temporal hairline (Gillies incision) for zygomatic fractures
• Upper lid blepharoplasty incision is used for frontozygomatic area
• Orbital oor through transconjunctival incision
• Maxilla and fragments through the sublabial and gingivobuccal
incisions.
■ Areas called as pillars or buttresses require due consideration for adequate results after fracture xation (also see Chapter 17). ese include
horizontal and vertical buttresses. ese are important to provide
support to facial architecture during jaw movements. Most repairs are
performed using titanium plates and screws.
■ Dental occlusion is paramount in severe midface fractures and is
established by use of arch bars.
■ Upper third fractures involve frontal sinus and often get complicated by
sinusitis. If the repair hampers the outow, cranialization or obliteration
may be considered.
251Chapter 19 Sinonasal Trauma and Cerebrospinal Fluid Rhinorrhea: Surgical Aspects
CEREBROSPINAL FLUID RHINORRHEA (CSF RHINORRHEA)
■ Causes of CSF rhinorrhea can be traumatic or nontraumatic. Most
common cause of CSF rhinorrhea is trauma, either accidents or injury
Section 4 Trauma252
to skull base during operative procedures (nasal and neurosurgical
procedures).
■ Nontraumatic causes include neoplastic or nonneoplastic intracranial
hypertension, skull base osteomyelitis, etc.
■ Idiopathic CSF rhinorrhea is rare and most have etiology like benign
intracranial hypertension associated.
Symptoms
■ Clear watery discharge typically unilateral but can be bilateral. e
discharge is more when patient bends forward (teapot sign).
■ e more common conditions like allergic rhinitis may produce similar
watery discharge and dierentiating the two can be challenging.
Signs
■ “Halo sign” is an important clinical sign. A halo around a blood spot is
indicative of CSF.
■ An associated meningocele or meningoencephalocele may be visualized
on endoscopy.
Investigations
Investigations should be aimed at conrming the uid to be CSF and
evaluation of exact site of leak. Frequently false negative, estimation of sugar
in collected nasal uid can help dierentiate it from nasal uid.
■■ Β2 transferrin, though a more accurate test for conrmation, is not readily
available and is costly.
■ Intrathecal agents like uorescein (0.1 mL of 10% in 10 mL of patient’s own
CSF). Radioactive iodine labeled serum albumen or other radioisotopes
can be used for radionuclide cisternography.
■ Imaging is detailed in Chapter 18, and is critical to localize the site of leak.
Management
■ Conservative management: Traumatic CSF leaks often heal without
surgical management. Head end elevation, avoidance of straining,
tapping of CSF with lumbar catheters are often successful, if strictly
employed for 1–2 weeks.
■ Surgical management: Leaks which fail conservative management and
spontaneous leaks frequently require surgical repair. Conventional transcranial repair is rarely required nowadays as most cases can be handled
endoscopically. Accurate identication of site of leak is para mount before
embarking on surgical correction. e area is adequately exposed and
surrounding mucosa elevated. Any meningoencephalocele is reduced
by bipolar cauterization.
■ e area is suitably grafted. Choice of graft material varies. We have
been using fascia lata placed in onlay or underlay fashion with excellent
results. Larger defects require cartilage or bone for bony defect
reconstruction. Fascia layer is supplemented with diced abdominal fat
or glue.
■ Nasal packs are kept for 3–4 days. Patients are nursed with antibiotics,
mannitol (to lower CSF pressure), and stool softeners.
■ Revisions and recurrences may require transcranial repair.
BIBLIOGRAPHY
1. Chegar BE, Tatum SA. Nasal fractures.In: Flint PW, Haughey BH (Eds). Cummings
Otolaryngology–Head and Neck Surgery, 6th edition. Canada: Elsevier; 2014. pp.
583-97.
2. Citardi MJ, Fakhri S.Cerebrospinal uid rhinorrhea. In: Flint PW, Haughey BH
(Eds). Cummings Otolaryngology–Head and Neck Surgery, 6th edition. Canada:
Elsevier; 2014. pp. 944-58.
3. Hill JD, Stoddard DJ, Hamilton GS. Facial trauma: soft tissue lacerations and
burns. In: Flint PW, Haughey BH (Eds). Cummings Otolaryngology–Head and
Neck Surgery, 6th edition. Canada: Elsevier; 2014. pp: 383-402.
4. Kellman RM. Maxillofacial trauma. In: Flint PW, Haughey BH (Eds). Cummings
Otolaryngology–Head and Neck Surgery, 6th edition. Canada: Elsevier; 2014. pp.
403-31.
253Chapter 19 Sinonasal Trauma and Cerebrospinal Fluid Rhinorrhea: Surgical Aspects
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