ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10001-1550 |
Skull Base Fracture: Management in the Acute Phase
1-4,7Department of Neurosurgery, Hospital Joseph Ravoahangy Andrianavolana, University of Antananarivo, Madagascar
5Department of Neurosurgery, Hospital of Soavinandriana, University of Antananarivo, Madagascar
6Department of Neurosurgery, Hospital Tambohobe, University of Fianarantsoa, Madagascar
Corresponding Author: Rasolonjatovo E Charles, Department of Neurosurgery, Hospital Joseph Ravoahangy Andrianavolana, University of Antananarivo, Madagascar, phone: + 261341316855, e-mail: charlesrasolonjatovo@gmail.com
Received on: 25 January 2023; Accepted on: 03 March 2023; Published on: 08 June 2023
ABSTRACT
Aim: Skull base fractures represent 7–16% of head injuries and mainly affect the active and young population. The aim of this article is to report the epidemiological, clinical, anatomopathological, and therapeutic aspects of skull base fracture in adults treated in the neurosurgery department of our hospital.
Materials and methods: This was a retrospective, descriptive study of skull base fractures hospitalized from 1st January 2019 to 31st December 2021. The epidemiological, clinical, anatomopathological and therapeutic aspects of skull base fracture were analyzed.
Results: We collected 168 cases of skull base fracture. Young male adults were predominantly affected, with a mean age of 33.69 ± 13.70 years. The main cause was road traffic accidents (79.8%). The Glasgow score was 14 and 15 in 95.8% of cases. Around 17% of patients had cerebrospinal fluid (CSF) rhinorrhea and 7.7% had CSF otorrhea. All patients had undergone a brain scan. The fracture was located at the anterior skull base in 102 cases (60.7%) and at the temporal bone in 65 cases. Antibiotic prophylaxis was systematically prescribed for all patients. Pneumococcal vaccination was performed in 19.6% of patients. The posttraumatic hematoma was the main indication for surgical treatment. Duraplasty was indicated because of persistent rhinorrhea. There were two cases of bacterial meningitis among the CSF leaks. Two cases of death were recorded (1.2%), the cause of which was sepsis from bacterial meningitis and cerebral involvement following diffuse axonal injury.
Conclusion: The results of medical and surgical management of skull base fracture in our context were favorable. Prevention of infectious risks, including vaccination, should be mandatory.
How to cite this article: Charles RE, Miantsa HZ, Radotina A, et al. Skull Base Fracture: Management in the Acute Phase. Int J Head Neck Surg 2023;14(2):17-20.
Source of support: Nil
Conflict of interest: None
Keywords: Antibiotic prophylaxis, Cerebrospinal fluid leak, Posttraumatic hematoma, Skull base fracture.
INTRODUCTION
Skull base fractures represent 7–16% of head injuries. It mainly affects the active and young population. Skull base fractures are often ignored or even neglected in comatose patients. The diagnosis of skull base fracture is essential because of its serious complications, including meningitis in case of CSF leakage, vascular lesions, and cranial nerve palsies.1 The main objective of this study is to report the epidemiological, clinical, anatomopathological, and therapeutic aspects of skull base fracture in adults in our center.
MATERIALS AND METHODS
This was a retrospective descriptive study conducted in the Neurosurgery Department of the Joseph Ravoahangy Andrianavalona University Hospital (CHUJRA), Antananarivo, Madagascar, from 1st January 2019 to 31st December 2021. All patients aged 16 years and older, hospitalized for a skull base fracture operated or not, were included in this study.
The following parameters were studied:
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Epidemiological parameters—age, gender, etiology, location, and frequency of skull base fracture.
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Clinical parameters—state of consciousness (Glasgow), rhinorrhea (yes/no), otorrhea (yes/no), periorbital ecchymosis (yes/no), epistaxis (yes/no), mastoid ecchymosis (yes/no), anosmia (yes/no), and signs of damage to the cranial nerves.
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Paraclinical parameters—tomodensitometric characteristics of the lesions, biological examination (cytochemical and bacteriological examination of the CSF).
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The evolutionary parameters—good evolution, complications, (infectious, functional, and vascular) and death.
Treatment protocol for patients with a CSF leak:
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Antibiotic prophylaxis, including the association of cephalosporins and phenicols for a period of 7 days with the single dose vaccine of Pneumococcal and Haemophilus influenzae type B.
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These groups of patients were kept in a supine position with a CSF discharge test every 48 hours. Standing up was allowed after the cessation of discharge.
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Surgical repair of osteomeningeal breaches is reserved for persistent CSF leaks beyond the 7th day of treatment.
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The criteria of favorable evolution are the following—absence of CSF leaks from the 7th day of treatment, absence of meningitis and or meningoencephalitis, and total recovery of functional signs related to damage to the cranial nerves at 3 months of evolution.
Data entry was done using Microsoft Excel software. The data were analyzed using IBM Statistical Package for the Social Sciences Statistics 20.0 and Microsoft Excel. Text processing was done using Microsoft Word.
RESULTS
During the period studied, 2,182 patients were hospitalized in the neurosurgery department for head injuries and or craniofacial injuries and or polytrauma in adults. We recorded 168 cases of skull base fracture; the frequency was 7.7%, with an average of 42 cases annually. Most patients were between 26 and 45 years of age, that is, 42.9%. The mean age was 33.69 years, with a standard deviation of 13.70. We found a male predominance with a sex ratio of 6.63. The skull base fracture was the result of a traffic accident in 79.8% of cases and fall in 11.9% of patients (Fig. 1). For those who were victims of traffic accidents, 66.3% were due to two-wheeled vehicles and 33.7% by cars.
Fig. 1: Distribution according to the etiology of trauma
The Glasgow score was 14 and 15 in 95.8% of cases. Around 29 patients (17.3%) had CSF rhinorrhea and 13 patients (7.7%) had CSF otorrhea (Table 1). There were 16 cases of anosmia (9.5%), seven patients (4.6%) with facial paralysis and three cases of hypoacusis.
| Signs | Number of cases | Proportion (%) |
|---|---|---|
| CSF rhinorrhea | 29 | 17.3 |
| CSF otorrhea | 13 | 7.7 |
| Otorrhagia | 61 | 36.3 |
| Epistaxis | 78 | 46.4 |
| Periorbital ecchymosis | 55 | 32.7 |
| Mastoid ecchymosis | 25 | 14.9 |
| Anosmia | 16 | 9.5 |
CSF, cerebrospinal fluid
All patients had undergone computed tomography (CT) brain scans. The fracture was in the anterior skull base in 102 cases (60.7%), with a predominance of the midfacial location in 50 patients (49%). One patient presented with a fracture of the roof of the orbit and the right frontal sinus, causing a compressive pneumocephalus of the frontal lobes, resulting in the Mount Fuji sign (Fig. 2).
Figs 2A to C: (A and B) Craniofacial CT scan showing a roof fracture of the orbit and the right frontal sinus (C) causing compressive pneumocephalus of the frontal lobes with Mount Fuji sign
Middle skull base location was predominantly at the level of the petrous bone in 60 cases (92.3%), of which the longitudinal fracture was 77% (Table 2). Pneumocephalus, extradural hematoma, contusion, edema, and subdural hematoma were the most common intracranial lesions, with proportions of 50.21, 13.1, 12.5, 8.9, and 7.7%.
| Fracture topography | Total (n = 168) | Proportion (100%) |
|---|---|---|
| Anterior skull base | 102 | 60.7 |
| Mediocraniofacial | 24 | 23.5 |
| Mediofacial | 50 | 49 |
| Laterofacial | 28 | 27.5 |
| Middle skull base | 65 | 38.7 |
| Longitudinal temporal bone | 50 | 77 |
| Transversal temporal bone | 10 | 15.4 |
| Tympanic bone | 5 | 7.7 |
| Posterior skull base | 1 | 0.6 |
| Occipital condyle | 1 | 0.6 |
Around 11% of the patients had a CSF examination and 1.2% of the examinations revealed Streptococcus pneumoniae (S. pneumoniae).
Concerning the management, antibiotic prophylaxis was systematically prescribed in all 42 patients (25%) who had a CSF leak. Around 34 patients were properly vaccinated against antihemophilic influenza B and pneumococcus, and eight patients received one dose of the pneumococcal vaccine alone.
A total of 20 patients (11.9%) underwent surgery. The main indication was compressive intracranial hematoma (extradural hematoma and acute subdural hematoma) in 95%. Osteomeningeal breach surgery was performed in 5%.
The evolution was favorable in 97.6% of cases. There were two cases of bacterial meningitis among the patients with CSF leak.
There were two cases of death (1.2%) secondary to bacterial meningitis and one case of cerebral involvement by intracranial hypertension. Two cases of facial paralysis and three cases of complete anosmia persisted beyond 3 months of evolution.
DISCUSSION
The epidemiology of skull base fractures varies by country. In the United States, according to the American College of Surgeons National Trauma Database, 8,33,311 adult trauma admissions were reported by 805 facilities. Approximately 36% were for a head injury. Approximately 7–16% of head injuries involve a skull base fracture.1 In China, 2019 data stated that out of 9,006 head injury patients, the frequency of skull base fracture was 8.5%. Compared to our study, these figures are similar.
The predominance of males and the young age of the population in our study is consistent with the literature.2,3 This could be explained by the active youth of the Malagasy population. Nowadays, a traffic accident is the main cause of trauma, including skull base fracture, which is proven in the literature.4,5 This could be explained by the emergence of two-wheeled vehicles, especially in urban areas.
Posttraumatic CSF discharge followed by pneumocephalus are the main signs suggestive of an osteomeningeal breach. In France in 2013, Schoentgen et al. found that 65% of anterior floor trauma presented posttraumatic rhinorrhea.3 Constanzo et al. described 40% of cases of posttraumatic rhinorrhea.6 Our study found 23 cases, or 17.3%, of posttraumatic rhinorrhea. The frequency of rhinorrhea during a fracture of the anterior skull base in our study is lower than in the literature. This could be explained by the fact that our study focuses on fractures of the anterior skull base.
The finding of CSF otorrhea requires a high-resolution CT scan of the petrous bone. Other studies concerning the fracture of the petrous bone in the literature have found a high frequency of otorrhea.7 In our study, only 13 cases, or 7.7%, had CSF otorrhea.
Posttraumatic meningitis is a serious progressive complication of skull base fractures. The precursor sign is the CSF leak. Sometimes the diagnosis of an osteomeningeal breach is only made by the discovery of purulent meningitis. The clinical picture is a febrile meningeal syndrome whose diagnosis is confirmed by cytochemical and bacteriological examination of the CSF.2 The most frequently encountered pathogen is S. pneumoniae.3,8 Yellinek et al. described that among 107 patients that had a CSF examination, only 4% had meningitis.4 Around 10% of the patients that underwent CSF examination had meningitis, according to the study by Schoentgen et al.3 In our study, two patients had meningitis despite adequate management. Only 11.6% had a CSF examination, and 1.2% of the cases showed S. pneumoniae. The low rate of CSF examination is explained by the high cost and the fact that its prescription is limited to patients who have presented with clinical signs of meningitis.
Depending on the anatomical location of the fracture, most anterior skull base fractures occur in the midfacial region. The fracture lines are complex in most cases1. In our study, midfacial trauma was the most frequently encountered, that is, 68.62%, followed by latero-craniofacial trauma in 30% of cases. Mediocraniofacial trauma represented 26.47% of cases. The reason is that this was the main point of impact of trauma in our cases.
The temporal bone is always affected in the mid-skull base. The longitudinal fracture type is more common (80–90% of temporal bone fractures) and results from temporoparietal impact.9 In our case, out of the 66 cases of petrous bone fractures, 77% were longitudinal fractures, and 15.4% were transverse fractures. Longitudinal fracture is the most frequently encountered fracture of the petrous bone and is especially a source of osteomeningeal breach.
For drug management, antibiotic prophylaxis was systematic in patients who presented with CSF leakage. The combination of cephalosporin derivative and phenicoles was prescribed in our management protocol. The efficacy of phenicoles derivative is proven for the treatment of meningococcal and hemophilus influenza meningitis.
Cephalosporins are effective against pneumococcus even if it has resistance to certain strains. This is a short-term antibiotic prophylaxis to avoid the side effects of the product. Our therapeutic drug regimen is like that in the literature.10,11
Vaccination against pneumococcal disease (pneumovax®) and hemophilus influenza B is an integral part of the treatment of skull base fractures. It should be renewed every 5 years.10 Vaccination was indicated for all our patients who presented with signs of osteomeningeal breach. This is similar to the cases described in the literature.2,3
Regarding surgical treatment, any persistent cerebrospinal rhinorrhea or otorrhea, any posttraumatic meningitis, and any craniocerebral wound justify the surgical indication. However, surgery is indicated in the case of compressive extradural hematoma or acute SDH or in the case of important esthetic sequelae.2 In our study, 11.9% of patients underwent surgical treatment. The main surgical indications were compressive and symptomatic extradural hematoma (95%) and osteomeningeal breach (5%). Schoentgen et al., on the contrary, surgically treated 72.3% of patients who presented with an osteomeningeal breach.3 In cases of symptomatic and compressive pneumocephalus, surgery is indicated to evacuate the air and repair the breaches.12 In our case, an asymptomatic case of compressive pneumocephalus of the frontal lobes with the sign of Mount Fuji,12 was treated conservatively, similar to the case described by Sweni et al.13
CONCLUSION
Skull base fractures are quite frequently encountered in cranial and craniofacial trauma. The most feared risk is the presence of an osteomeningeal breach, which can lead to posttraumatic meningitis. Treatment is multidisciplinary. Prevention of infectious risks, including antibiotic prophylaxis and vaccination, must be mandatory.
The role of surgery in the management of an osteomeningeal breach is secondary. Thus, the search for the skull base fracture must be systematic during cranioencephalic trauma, even in comatose patients. This study shows the effectiveness of conservative treatment, for which an analytical, prospective and comparative multicentric study is necessary.
ETHICS
As this was a retrospective study, ethics approval and participation consent were waived.
ACKNOWLEDGMENTS
All authors read and approved the final manuscript.
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