Abstract
Introduction:
Cerebrospinal fluid (CSF) fistulas that follow anterior skull base fractures pose unique challenges in surgical repair because of the intimately associated anatomical relationships of paranasal and intracranial structures. We describe the evolution in management of these patients over a 10-year period. We introduce a classification scheme for these fractures to stratify surgical treatment options. Endoscopic and microsurgical repair with the use of a lateral temporoparietal fascial flap, nasoseptal flap, and anterior pericranial flaps are described and employed based on the classification.
Methods:
A total of 43 patients were surgically treated at our institution between January 2004 and May 2014 for anterior skull base fractures with CSF fistula. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Patients were classified according to posterior fracture extent: Class I—Frontal bone/sinus involvement only, Class II—Extent to ethmoid-cribriform plate, Class III—Extent to sphenoid bone/sinus. Orbital osteotomy, surgical microscope, and endonasal endoscopic approaches were utilized and treatment options were guided by fracture classification.
Results:
Overall, 6 fractures were classified as Class I, 8 as Class II, and 29 as Class III. Exclusive anterior pericranial flap was used in 33 patients (77%), 2 of whom had persistent CSF leak. Multiple flaps were used in 10 patients (23%), 1 with Class II and 9 with Class III fractures; no CSF leaks were seen in these patients. No patients managed following integration of microscopic, endoscopic, or combined tissue flap repair techniques had postoperative CSF leak. Average follow-up was 13.7 months. Overall, two patients developed meningitis during the postoperative hospital course. Both resolved following antibiotics.
Conclusion:
Comminuted anterior-skull-base fractures often require an aggressive treatment approach to provide the greatest long-term functional and cosmetic benefits. Integrating the use of operative microscope, orbital osteotomies, along with the combined use of the nasoseptal and temporoparietal fascial flaps are an effective and often necessary means to repair CSF fistulas following extensive trauma to the anterior skull base. These techniques can be tailored based on the fracture extent and classification.