gms | German Medical Science

Objective: Frontobasal fractures occur in 24% of head injuries. These fractures often are associated with cerebrospinal fluid (CSF) leakage and possible meningitis as well as mucocele development. While some surgeons only will operate in case of persistent CSF rhinorrhea, we tend to surgically explore for possible dural laceration in cases of frontobasal fractures involving the posterior wall of frontal sinus, the cribiforme plate, or the sphenoid sinus to minimize the risk of meningitis or mucocele development. We aim to retrospectively evaluate intraoperative findings and clinical course in relation to preoperative imaging to assess the significance of early revision surgery.

Methods: We conducted a retrospective analysis of 49 consecutive patients undergoing early revision surgery for frontobasal fractures. Preoperative computed tomography scans (CT) were reviewed to define the extent of fracture and were correlated to findings described in the operative notes. Furthermore, we evaluated the postoperative course and specifically noted development of rhinorrhea, bacterial meningitis, and mucocele. Typically, surgeries were performed together with colleagues from the craniofacial surgery team; a trans-frontal sinus route was preferred.

Results: Forty-nine patients were included in the study (92% males). The majority of patients suffered from falls (47%) or motor vehicle accidents (43%). The indication for surgery were fractures of the posterior wall of the frontal sinus (89.8%, displaced in 55.1%) or of the cribiform plate (49.0%, displaced in 10.2%), partially associated with intradural air inclusions in 81.6%. Concomitant mid facial fractures were found in 71% and orbital fractures in 69% of the patients. Of all patients, 24.5% patients suffered from CSF rhinorrhea preoperatively. Intraoperatively, a dural laceration accompanying the fracture identified by preoperative imaging was found in 92% of patients and was microscopically sutured; this included all patients with a preoperative rhinorrhea. Correlation between intraoperative findings and air inclusions on the trauma scan could not be established, suggesting that CT scan criteria for dural laceration are non-predictive.

Conclusion: Early frontobasal revision surgery via the trans-frontal sinus route for frontobasal fractures of the posterior wall of the frontal sinus or of the cribiform plate will demonstrate dural lacerations in nine out of ten patients and offer the possibility for surgical repair. With a sufficient surgical dural repair, typical severe complications of frontobasal fracture are minimized.