Dose Determination for Hydrophilic and Lipophilic Drugs for Chemotherapy and Immunotherapy

Research Article

Austin J Clin Med. 2018; 5(1): 1034.

Long-Term Results after Extra-Cranial Skull Base Reconstruction - A Cohort Study

Kemper M¹, Marschke T², Cuevas M¹, Reden J¹, Osman ME¹, Zahnert T¹, Schackert G³ and V Gudziol1*

¹Department of Otorhinolaryngology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany

²Department of Anesthesiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany

³Department of Neurosurgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany

*Corresponding author: Volker Gudziol, Department of Oto-Rhino-Laryngology, Dresden Medical School, Technical University Dresden, Fetscherstr. 74, 01304 Dresden, Germany

Received: May 15, 2018; Accepted: June 20, 2018; Published: June 27, 2018


Indication for post-traumatic skull base reconstruction differs widely among the institutions. The aim of the present study was to assess the long term outcome following skull base reconstruction in a single institution.

Methods: 138 of 404 patients undergoing surgical skull base revision after trauma received follow-up examination. Skull base reconstruction was performed because of meningitis (1.4%), rhinoliquorrhoea (5.7%), intracranial air (58.2%) and fracture lines in the CT scan (100%). The surgical approach was transnasal endoscopical in 101 sides and extra-cranial external in 92 sides. Eleven sides were operated with a combined procedure.

Results: Intraoperatively Cerebrospinal Fluid (CSF) leakage could be found in 14% of the patients who had no clinical signs of rhinoliquorrhoea preoperatively. Postoperatively, 3.6% and 2.2% of the patients developed rhinoliquorrhoea or meningitis, respectively. Significantly less mucoceles developed following transnasal compared to external approaches (p=0.006).

Conclusion: In 14% surgical rhinobase exploration unveils dura laceration with CSF-leakage in patients who demonstrate rhinobase fractures in the CT-scan and have no clinical signs of rhinoliquorrhoea. Transnasal endoscopic surgery should be favored for skull base reconstruction in order to reduce the incidence of mucoceles.

Keywords: Skull Base; Traumatic Brain Injury; Basilar Skull Fracture; Cerebrospinal Fluid Rhinorrhea Mucocele; Compliance with Ethical Standards


The present study is about skull base fractures involving the osseous walls of the nasal cavity and the paranasal sinus. In the literature the terms “skull base fracture”, “front basal fracture” or “anterior skull base fracture” are used to describe this condition. To be precise, a skull base fracture does not necessarily involve the walls of the paranasal sinuses and/ or the nasal cavity. The front basal region anatomically consists of the frontal sinus and the median third of the superior orbit rim. The anterior cranial base is formed by the nasoethmoid, the cribriform plate and the planum sphenoidale (Manson 2009 Frontobase: anatomical classification). Fractures of the walls of the sphenoid sinus involving other parts than the planum sphenoidale can have contact to the dura mater of the middle and posterior cranial fossa. Strictly speaking, these fractures cannot be described as anterior cranial base fractures. The expression “rhinobase fracture” was suggested by some authors in order to summarize frontobasal, anterior skull base and sphenoid sinus fractures that are not contained in the latter expressions. Additionally, “rhinobase fracture” expresses the anatomical relationship between the skull base fracture and the paranasal sinuses or nasal cavity [1].

Potential consequences of traumatic disruption of the bony rhinobase, the dura mater and arachnoid membrane can be 1) rhinoliquorrhoea with possible consecutive pneumocephalus and 2) intracranial hemorrhage. Disruption of the natural barrier between the contaminated paranasal sinuses and the brain can lead to ascending bacterial infections that result in e.g. bacterial meningitis in up to 85% of the patients with rhinoliquorrhoea [2, 3]. A meningitis rate of up to 24% is reported in patients with skull base factures without clinical signs of rhinoliquorrhoea and/or intracranial air [4-6]. Bacterial meningitis can appear as early as days after the trauma but also years after the head injury [7].

Surgical reconstruction of the rhinobase is suggested with intent to reduce the early and late onset sequelae of rhinobase fracture related complications.

Indication for rhinobase reconstruction differs widely among different study groups. Several experts recommend rhinobase reconstruction in case of rhinoliquorrhoea [8,9]. Others justify conservative therapy in cases with self-limiting rhinoliquorrhoea [9,10]. A London based group recommended surgery in patients with intracranial air or displacement of the fracture by more than the thickness of the bone [11]. Another center advocates rhinobase exploration without clear clinical and radiological signs of dura laceration [12]. Schoentgen and co-authors summarize that there is no common consensus for diagnosis and treatment of rhinobase fractures, at present [10].

Extra cranial skull base reconstruction entails the risk of acute intra- and perioperative complications and also longtime sequelae. Most frequently reported sequelae are meningitis, recurrent CSF leakage and mucoceles [12]. Each physician´s goal is it to reduce rhinobase fracture related complications while reducing the patient´s risk to suffer from surgery related complications or sequelae. The present study does not aim to answer the debate when to perform skull base reconstruction but to investigate the long term outcome after rhinobase reconstruction in a single institution.


This single institutional cohort study was approved by the responsible ethic board at Dresden medical school, Technische Universität Dresden/ Germany. Patients gave written consent to participate in the study.

Electronic surgical reports of the Department of Otorhinolaryngology at the TU Dresden Medical School were screened for the German key words indicating skull base reconstruction for a 10 years period (October 1998 to October 2008). Inclusion and exclusion criteria are indicated in Table 1. In the above mentioned period indication for skull base reconstruction was seen when there was either one or multiple of the following conditions: β-trace or β- transferrin proven rhinoliquorrhoea, intracranial air, and a visible fracture line in the skull base with contact to the nasal cavity and/or the paranasal sinuses in the Computed Tomography (CT) scans. In general, surgery was performed when the patient was in a stable condition. In case of a communicating wound between the skin and the fractured skull base, rhinobase reconstruction was performed immediately after hospital admission. Additionally, rhinobase reconstruction was performed urgently when there was massive rhinoliquorrhoea and pneumocephalus in order to prevent intracranial hemorrhage due to disruption of intracranial vessels. The surgical approach was set according to the localization of the fracture, additional midfacial injuries or brain injuries and the personal experience of the surgeon. Patients were placed in 30° head and upper part of the body down position (Trendelenburg positioning), jugular veins were compressed bilaterally, Positive End-Expiratory Pressure (PEEP) was increased and intrathecal fluorescein was used in order to visualize the CSF-fistula intraoperatively in indicated cases. Lacerated dura mater and/or the fractured bony skull base were closed mainly with xenografts and fibrin glue or local flaps and fibrin glue. Patients were set on intravenous cephalosporins at the time when rhinobase fracture was diagnosed. Nasal packing was placed until the 2nd or 7th postoperative day.