gms | German Medical Science

Objective: The indication for a treatment of frontobasal fractures with apparent CSF fistula or proven intradural air enclosure is generally accepted. The necessity of a frontobasal coverage in cases of fractures without CSF fistula or only epidural air enclosure is discussed controversially. For a correct risk-benefit analysis, the results both of spontaneous courses and of surgically treated cases are mandatory. However, a long-term follow-up of spontaneous courses is difficult. Studies are often limited to a small number of cases. In this context the operative morbidity gains special importance concerning the indication for surgery. We present our interdisciplinary treatment concept for frontobasal injuries and discuss intraoperative findings and postoperative results.

Methods: A uni- or bilateral frontal craniotomy is performed. Depending on the involvement of the frontal sinus, it can be preserved or is cranialised. Injuries of the midface are treated in an interdisciplinary mannerat the same time. After opening of the dura and adequate CSF drainage, the frontal lobes are retracted gently. The arachnoid membranes fixing the olfactory nerves to the frontal lobes are dissected. By this technique preservation of the olfactory function is possible since the olfactory nerves remain lying on the skull base while the frontal lobes can be mobilized. The entire frontobasis including the olfactory nerves is covered with a vascularized galea-periost-flap. Fixation is done with sutures and fibrin glue. A lumbar CSF-drainage is placed for 5-7 days.

Results: The surgical procedure is demonstrated with intraoperative illustrations, schematic diagrams and video sequences. In all 37 patients definite dural defects could be identified intraoperatively. Although frequently one olfactory nerve was injured due to the trauma, in all cases at least one olfactory nerve could be preserved anatomically. More than 90 percent of the patients reported a normal smell perception in the postoperative course. No persistent CSF fistulas occurred. A rare complication was brain swelling due to CSF overdrainage. In the group of primarily treated patients, no infections occurred.

Conclusions: The simultaneous interdisciplinary treatment of frontobasal and midface injuries has been proven. The morbidity-risk associated with the demonstrated operative procedure appears justifiable compared to the potential impairments in spontaneous courses. The presented intradural surgical technique provides a reliable CSF-proof coverage and allows the preservation of olfactory function.