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Post-traumatic cranial defects in the anterior fossa
Post-traumatic Cranial Defects the Anterior Fossa PAUL H. CRANDALL, M.D., Los Angeles,
From the Department of Surgery, University oj Calijornia Medical Center, Los Angeles; and tbe Wadsworth General Hospital, Veterans Administration Center, Los Angeles, California.
is apparent that the anterior fossa of the skuI1 is the most vulnerable region for fracturing and contaminating injury in craniocerebra1 trauma. Although antibiotics have allowed the surgeon a greater Iatitude in treatment, nevertheIess a communication between the nasopharynx and intracranial contents remains a dangerous condition. Even though the immediate infection is controIled, the surgeon may still be confronted with the problem of recurrent bouts of serious iIlness. The probIem is IargeIy soIved if the condition is soon recognized and the communication properI? and effectiveIy seaIed during the acute stage of head injury. This articIe presents an anaIysis of twentytwo cases of cranial defects in the anterior fossa. Eighteen patients were encountered and treated by the author at the 97th General HospitaI, Frankfurt, Germany, between October 1952 and June 1954, whiIe four patients were seen from August 1954 to August rggg at the Wadsworth Genera1 HospitaI, Veterans Administration Center, Los AngeIes, CaIifornia. AI1 cases were traumatic in origin, demonstrating either cerebrospinal fluid rhinorrhea, intracrania1 air, or at operation fractures into the paranasal sinuses with meningea1 tears in the anterior fossa floor.
I
T
MECHANISMS OF INJURY In any head injury three effects are transmitted from the applied force: (I) the deformation of the skuI1 with or without fracture, (2) the rotation of the brain within the calvarium, and (3) the deveIopment of compressiona or
in
Culijornia
“rarefactional” strains within the brain along the direction of the appIied force. Deformation of the skuI1 depends on the veIocity of the impact and the size and shape of the striking object. The tensile strength varies with the age, sex and race of the patient. Studies by Gurdjian, Webster, and Lissner [I] have shown that a high velocity bIunt object causes Iocal circumscribed fracture and depression. Low velocity blunt impact causes an area of inbending at point of impact and, at considerable distance, an area of outbending in which a Iinear fracture may form. The linear fracture propagates both toward the point of the blow and in the opposite direction. Rotation effects are greatest in producing laceration or tearing of bIood vessels and occur wherever contour of the skuI1 permits gIiding of the brain, i.e., parietal and occipita1 regions [2]. In force applied to the fronta regions, the contour of the anterior fossa ffoor, the sphenoid ridge and the faIx cerebri Iimits this rotation so that shear strains onIy are produced in most instances. In the opinion of Holbourn [?I, the compressiona1 or rarefactiona1 strains are not thought to be especiaIIy injurious. Therefore, in direct frontal injuries it is the fracturing of the skuI1 and the shear strains within the Iobes which are of most importance. My observations are mainly directed to the mechanisms of fracturing and subsequent contamination. It is obvious from the foregoing that anatomic features also infIuence the fractures which are produced. In the base of the skuI1 and proIonged up into the vauIt are the buttresses of the sphenoid ridge, and aIong the former metopic suture. The supraorbita1 ridges form a horizontal arch. A linear fracture at a right angIe to a buttress wiII pass through, but at
CrandalI fragments in the ethmoid roof seem to disappear and leave an almost oval-shaped aperture \vitll lacerated dura overlying. One additional factor ma>. be important in the production of fractures. The tough, inelastic falx attaches to the crista galli, and in depressed fractures stretching the falx ma>. wrench the ethmoicl bone ancl its connections. 1 have found that the fractures of the anterior fossa floor which result in craniosinus fistula deveIop from several sources. They may be the result of linear fractures radiating from the vault, from depressed fracture low on the vault, from facial injury or from force directed at the base of the skull. For convenience 1 have divided them into four groups. FRONTAL
FIG. I. TrnnsiIlumination of dried skuI1, displaying the buttresses and ridges of bone with relation to thr p:uxnasaI sinuses.
other angles \vill be diverted to run paraIle1 to it. The structure of the anterior fossa floor is such as to predispose it to isolated fractures. (Fig. I.) The thin bone of the floor is irregular in contour and thickness due to the convoIutional markings. Inset is the depression of the cribriform plate with the delicately waIIed ethmoid cehs at each side and the larger frontal and sphenoida1 sinuses before and behind. Extending IateraIIy from the central region are two ridges of greater bony density; one into the orbital roof and the other at the IeveI of the posterior crihriform plate. These ridges of heavier bone may defIect a radiating fracture and turn it inward to these sinuses. The second unique characteristic of this region is the type of bone. The convoIutiona1 markings resuIt in several small eminences with thicker bone at the apex surrounded by thinner bone. The most prominent of these eminences form the roofs of the ethmoid ceIIs. A fissure wiI1 tend to run through the thinner bone around such an eminence, resuIting in a free fragment of bone. Not uncommonly, we have found that the
INJURIES
Nine patients suffered extensive injury with depressed fronta bone fragments, comminuted fractures of the paranasa1 sinuses and orbita roofs, and open fronta scaIp wounds. Two cases of an unusua1 nature were the resuIt of accidents in which soldiers were struck by a tire rim while inAating a truck tire under great pressure. Both injuries were identica1 in that large, bilateral depressed fronta fractures at the supraorbita1 IeveI were produced. The remaining cases arose from more common accidents, and most of them incIuded varying degrees of damage to the eyes. Immediate operation was undertaken in seven patients to repair extensive meningea1 tears. Such tears were frequently associated with moderateIy Iarge bony defects over the ethmoid sinuses and cribriform pIate. In two patients very Iarge defects in the sphenoid sinuses existed. Herniations of brain tissue aImost invariabIy accompanied such large defects. OnIy one instance of a simpIe Iinear fracture in the fronta region was encountered; the fracture passed through the right fronta sinus and radiated back into the ethmoid ceIIs. A pneumatoceIe was visibIe on the initia1 fiIms. TEMPORAL
FRACTURES
The presence of midIine crania1 and meningea1 defects may not be recognized in the instance of tempora1 fractures. The fracture may run in an arc-Iike fashion across the floor of the anterior fossa, resuIting in comminuted fractures in the roof of the paranasa1 sinuses. ParticuIar attention shouId be paid to this
Post-traumatic
Cranial
Defects
in Anterior
Fossa
midline complication of temporal fractures, and for this reason two case reports are appended. Six instances of temporoparietal fracture with craniosinus fistula were encountered. CASE I. A thirty-one year old white sergeant \vas found dead in his bed at 5:40 A.X on January 22, ‘954. Review of his past records revealed that in Korea, September, 1950, he had sustained a left, compound, frontotemporat skull injury that resulted in multiple foreign bodies in the left frontal lobe. Surgical removal of bone in this area was performed shortly thereafter. In November, 1950, he was treated for meningitis (alpha streptococcus), and in the spring of 1953 at a U.S. Genera1 Hospital a tantalum craniopIasty was performed to fill the left frontotemporal skuII defect. The pertinent autopsy findings incIuded a skull region defect, 5 by 3 cm., in the Iower temporal filled by a perforated metaIIic pIate. Another bony defect, 1.5 cm. in diameter, Iay in front of the cribriform pIate and communicated with the left frontal sinus in front and the ethmoid ceIIs behind. A third defect, 2 cm. in diameter, crossed the right orbita plate; the dura and overIying brain were adherent in this region. (Fig. 2.) was An irregular abscess, 6 cm. in diameter, found in the right fronta pole. It was hIIed with thick, green pus; the organism was cultured as pneumococcus. The overlying she11 of cerebral substances was thin, friable and markedIy adherent to the dura and defects at the base of the skull. Purulent exudate filled the subarachnoid spaces. The ependyma1 lining of the right ventricle was partiaily ulcerated and contained inflammatory exudate. Widespread toxemia was manifested by hemorrhages in the lungs, epicardium and skin; pneumococcus was aIso recovered from the bIood and pericardial fluid.
FIG. 2. Case I. Aboue: A Iarge cranial defect is present in the roofs of the anterior ethmoida1 ceIIs. Note also the tantalum pIate in the left temporal region. Below: The brain shows a right frontat abscess which extends across the midline and involves the Ieft frontat poIe as well.
there were many radiating fractures. At no time did he have any cerebrospinal rhinorrhea. ShortIy after admission both frontal lobe tracts were debrided and numerous pieces of bone, cIot and gunpowder were removed. A tracheotomy was performed and blood was administered. Fifteen days after injury anuria supcrvencd, and the patient died eighteen days after admission. Autopsy revealed muItipIe puImonary emboli, phIebothrombosis of the tibia1 veins, lower nephron nephrosis and a small, indurated duodenal ulcer. In addition to the skuI1 defects aIready described, an irregular corona1 fracture at the base of the skull extended between these two defects and invoIved the cribriform plate and the upper surface of the sphenoidal sinus, aIlowing a direct communication with the intracrania1 contents. A probe could be passed into the sinus and the nasal fossa. The undersurfaces of the fronta lobes were irregularly lacerated, with protrusion of the parenchyma into the right sphenoida1 sinus. No
CASE II. On March 7, 1954, at 10:35 P.M., a twenty-three year old Negro Air Force policeman was found unconscious behind his overturned jeep with a missiIe wound of the head. When admitted to the hospital he was in profound coma and shock, and had spasmodic, irregular respirations. Examination revealed punctate missile wounds in each temple. The right wound, which was filled with black gunpowder, was located 2 cm. behind the outer edge of the eyebrow. The left exit wound was at the hairline approximately 3 cm. above the zygomatic arch. There was bleeding from both nostrils, slight exophthalmos and a considerabIe sweIIing beneath the scaIp on both sides. The right pupil was wideIy diIated and fixed. The patient moved all extremities well. He was treated for shock, and roentgenograms of the skuI1 reveaIed rounded defects in both tempora1 areas from which 519
CrandaII Roentgenograms revealed fractures confined to the shell-like bones of both sides of the maxiIIa and sinuses. The IateraI limits of this block-Iike fragment could be seen cIearIy by fracture-separation of the zygomatic arches. LittIe or no radiation of the fractures into the supraorbital ridge was seen. The exact status of fractures within the facia1 bones is often diffIcuIt to determine. DISCRETE
FRACTURES
In this series at Ieast one case appeared to faI1 into this group of isoIated small fractures in the anterior fossa floor. CASE III. A twenty-eight year old corporal suffered from intermittent rhinorrhea caused by a severe head injury sustained in Korea in 1951. He had five attacks of meningitis, one of which was folIowed by right hemiplegia and aphasia. After craniotomy with attempted closure of the dura was undertaken in a U.S. Genera1 Hospital, the patient was free of rhinorrhea for severat months. Reoperation was undertaken at the 97th General Hospital Frankfurt, Germany, following his Iast episode of meningitis in May, 1954. A bony defect in an ethmoid roof was found and repaired. Adson [4] reported one case of a man who sustained a depressed skuI1 fracture at the vertex from the fall of a So-pound weight and who aIso had a discrete fracture of the anterior fossa ffoor.
FIG. 3. Case II. Above: Film shows a Iarge, bifrontal
fissure fracture and postoperative crania1 defect in the Ieft ternDora region. Note the marked tiItine of the crista gaili to the right. Below: Note biIatera1 ithmoid cell defects associated with the arc-like fracture of the anterior fossa floor.
CLINICAL
evidence of infection was found, although from the sinuses had exuded into the cavities. (Fig. 3.)
The principa1 manifestation of craniosinus communication is cerebrospina1 fluid rhinorrhea; of the twenty-two cases in this series, it was present in fourteen. Immediately after injury the rhinorrhea is a thin, bIoody fluid which becomes pink in one day and Iater is coIorIess and watery. The sugar content of the fluid was occasionaIIy heIpfu1 in identifying it as cerebrospina1 fluid. To avoid overIooking rhinorrhea and as a part of a physica examination, a11 unconscious or irrationa1 patients should be pIaced for a few minutes in the prone position with their faces dependent over the side of the bed. Ecchymoses, fluctuant sweIIings about the orbit and proptoses are aIso significant findings. These signs were noted in thirteen patients of the series. Nuchal rigidity (not attributabIe to meningitis, subarachnoid bIood, or injury to the neck) was often present, particuIarIy in those
mucus cranial
Comment on Case II. In this patient a massive defect existed without apparent rhinorrhea, and one which wouId have resuIted in compIications had not the aforementioned defects intervened. In retrospect, the anterior fossa ffoor wouId have been inspected and managed had the condition been suspected. Adequate, early x-rays are required even if anesthesia is necessary for a restIess patient. FACIAL
MANIFESTATIONS
INJURIES
Head-on bIows to the face may result in a bIock-Iike separation of the entire maxiIIa. The force is usuaIIy transmitted by the frontal process of the maxiIIa to the base of the anterior fossa. There were six such cases in this group.
52”
Post-traumatic
Crania1
Dlefects
in Anterior
Fossa
tions of air, and it is to this situation that I wish to caII specia1 attention. There were six such cases in this series. Since many forms of meningitis are now easiIy controIIed by various antibiotic drugs, it becomes important to consider the cause of the origina meningitis and, by radioIogic investigation, to determine if a fracture of the anterior fossa is present. In the foIIowing case the use of antibiotic drugs may we11 have actuahy fostered the deveIopment of chronic meningitis due to a fungus which may have gained ingress through default of other organisms.
patients with extensive damage at the base of the skuI1. It may be a valuabIe cIue to diagnosis. VisuaI heId defects from optic nerve invoIvement due to fracture of the optic foramen were found in seven cases. ExtraocuIar muscle involvement was present in eight cases. Three patients with massive frontal injury required enucleation for rupture of an eyeball. As in the instance of orbital fracture, injuries to orbital contents shouId Iead one to suspect nearby paranasal sinuses. Crepitation at the base of the nose usuaIIy indicates fracture of the nasa1 hones. In three cases, when the upper teeth were grasped, the whole block of maxiIIary bone couId be moved with ease and the contours of the face altered. No wiring could be done in the presence of the acute cerebral injury because of the difficulty of maintaining a good airway and the possibility of vomiting. After the rhinorrhea had spontaneously ceased, manipulation or wiring of the facia1 bones frequently resuIted in a temporary recurrence of the rhmorrhea. Despite the remarkable instability of the face, the fracture unions were firm in two to three weeks. As other authors [6,8] have pointed out, signs which are definitely indicative of a dural communication with the paranasal sinuses incIude aeroceles (flask-like collections in the frontal lobe substance) and pneumocephalus (collections of air in the ventricles or over the convexities via the subdura1 and subarachnoid spaces) [r~,r6]. Two such instances occurred in this series. Radiologic demonstration of the bony defect is of great importance. Stereoscopic posteroanterior views are heIpfu1 in tracing fissures. Tilting of the crista gaIli, as seen in Fig. 3, is sometimes observed. LateraI views that show buckling of the orbita roof and tiIting of the anterior clinoid process usuaIIy indicate defects in the ethmoid or sphenoida1 sinuses. Optic foramen views often help to show orbita fractures and some of the ethmoid ceIIs. Johnson and Dutt [r?] have deveIoped two projections, simiIar to the optic foramen view, that outline the ethmoid and sphenoida1 sinuses; the appearances are detaiIed in their articIe. These Iatter views, however, require excehent cooperation from the patient and the best radioIogic technic; even then they may be difficuIt to interpret. Craniosinus Fistulas Revealed Only by Meningitis. Craniosinus fistma can exist without cerebrospina1 rhinorrhea or intracrania1 cohec-
CASE IV. On December I I, 1954, a sixty-two year oId man was invoIved in an automobile accident, during which his head cracked against the windshieId. AIthough he sustained facial fractures, hemorrhage and a dislocated Iens in the right eye, and cornminuted fractures of the patella, he was not unconscious. Because of signs of infection in the eye, it was enucIeated. Shortly after admission to the Wadsworth General HospitaI on December 26th, radiographs of the skul1 showed fractures of the inferior rim of the orbit on the right, fractures of the nasa1 bones and a fracture of the posterior waI1 of the frontal sinus. From the time of injury the patient compIained of a constant miId headache, principalIy over the right fronta area. On March II, 1955, the patient was Iethargic, and during the next few days he had four episodes of nausea and vomiting, shaking chills and a temperature of 38.g’c. (102’F.). He aIso complained of increasing headaches. Lumbar puncture revealed a pressure of 160 mm. and 185 white ceIIs per cc., composed of 54 per cent poIymorphonucIear Ieukocytes and 46 per cent lymphocytes. During the remainder of the patient’s hospita1 course he ran a continuous Iow grade fever between 37.8’~. It was accompanied (I OO’F.) and 38.g”c. (I 02’F.). with a meningea1 cellular reaction averaging 300 white ceIIs per cc., the majority of which were poIymorphonucIear leukocytes. Total protein averaged 150 mg. per cent and gIobuIin 2 pIus. A total of fifteen cultures were made, six specifically for fungi; a11 were negative. Because of suspicion of brain abscess a ventriculogram was taken on ApriI 26th; it was entireIy negative. Antibiotic drugs were used from the time of the accident to the patient’s death, except for a period from February 9th to March I 7th. The patient was treated with various combinations of penicillin, sulfadiazine, erythromycin, chloramphenicol, tetracycline and oxytetracycline hydrochIoride. None of these agents affected his cIinica1 course, nor did they aIter the ceIIuIar reaction in the spina fluid. In JuIy increasing Iethargy and, at times, stupor
521
CrandalI fractures in the anterior fossa accompanied with rhinorrhea; (5) recurrent cerebrospinal rhinorrhea or recurrent bouts of meningitis. The question now arises as to jvhether (6) cerebrospinal rhinorrhea beginning at the time of injury is an indication for immediate intervention, and if not, just how long it should be aIlowed to persist before becoming one. Arbitrary limits have been set by certain authors according to their experience. Adson [d] allowed the condition to persist eight, weeks [9] two before undertaking repair, Dandy weeks, days
and
and complete disorientation developed. He had tremor which was irregular, coarse and charactcrized by some slight rigidity of a cogwhee1 nature and a slight motor restlessness in all extremities. On July 7th a second ventricuIogram reveaIed extremely thickened and greenish arachnoidal membranes and a very marked diIatation of the entire ventricuIar system. The patient died six months and twenty-seven days after injury. Autopsy examination disclosed that the calvarium was free of osseous abnormality except for the right ethmoid sinus. The brain in the inferior right frontal area adjacent to the defect showed a 1.3 cm. Iocalized area of herniation and mild softening where the brain parenchyma and oIfactory tract had protruded into the osseous defect. (Fig. 4.) There was a smaI1 quantity of moderately cIoudy seropurulent exudate over the base of the brain and the inferior right fronta herniation. A Ieft intracerebral hemorrhage in a ventricular needle tract was present. The basilar meninges were thick and encrusted with puruIent material, especially around the cerebeIIopontiIe angIe, interpeduncuIar space and the foramens of Luschka. Microscopic examination showed active chronic meningitis in the base of the brain incIuding foreign body giant ceII reaction and septated chIamydospore-forming organisms, probably aspcrgillosis. TREATMENT
In certain instances indications for operative intervention are obvious: (I) compound de(2) extensiveIy compressed fronta fractures; minuted
fractures
increasing
these
or
should
of
the
persistent
be
added:
anterior
fossa;
pneumocephaIus.
(4)
widely
(3) To
fissured 522
and
Webster
[12]
a “fe\\
the Radcliffe Inthat “Dural repair shouId be considered in al1 cases of paranasaI sinus fracture with rhinorrhea, whether it is of earIy or late onset., of brief or long duration.” This conclusion is based on a foIIow-up study varying from three to nine years. He followed up simiIar groups of cases in which no surgery was performed. CompIications of operation were aImost ni1, whiIe cases in which there was no surgery had a high incidence of Iate infections, recurrent rhinorrhea and mortaIity. In the present series certain observations in favor of Lewin’s conclusions were made. In those patients operated upon from ten days to four months after injury the natural processes of repair as observed at operation were deficient. Herniations of cerebra1 tissue with piarachnoidal adhesions to the dura mater at the edge of the defect were common findings. A web-like arachnoidal membrane over the defect was also frequentIy encountered. Previous meningitis did not seem to have increased the reparative process. It seems that the only instance in which successfu1 natural repair can be expected is that in which the dural edges are in contact without the interposition or interference of other tissue (i.e., bony spicules, mucous membranes, brain, and so forth). In any case of recurrence of rhinorrhea or meningitis, as we11 as in any case of widely fissured fracture, this idea1 natural approximation is not present. On the other hand, it was possible to perform the operative repairs without added neuroIogic deficit and, in most cases, with improvement. in the neurologic state. The principIes of cIosure of cranionasal f%tuIa have gradually evolved since 1927 when Cushing [7] reported the use of free fascia Iata grafts in patients from whom he had removed RecentIy
FIG. 4. Case III. Photomicrograph showing a pedunculated herniation of brain tissue with a centra1 core of malacia surrounded by marked gliosis. At autopsy the protrusion was through an osseous defect communicating with the right ethmoid sinus. OriginaI magnification, x6.
Gurdjian
only.”
firmary,
Lewin
Oxford,
[14],
concluded
at
Post-traumatic
Crania1
Defects
ethmoid exostoses. In 1926 Dandy [8] cIaimed to be the first to close a fistufa successfuIIv in a patient with spontaneous cerebrospinal rhinorrhea. Various materials have been used h,y different surgeons; bone wax and strips of muscle in the defect, temporalis fascia, tibia1 fascia Iata, periosteaf grafts [r I], pericranium, an d gelfoam@ sponge [6]. The extradura1 approach was almost universaIIy used unti1 Cairns and Lewin [r] used the intradural approach in treating sphenoidal sinus fractures with fistufas. A defect so far posterior required the intraduraf approach; it was also found easier and the resuIts of free facial grafting were equaIIy as good. SubsequentIy, during WorId War II British surgeons under the inAuence of Cairns used this method excIusiveIy and wideIy in treating missiIe wounds with cranionasal fistuIas, with exceIIent resuIts. In 1944 Gurdjian and Webster [12] recommended combined extradura1 and intradura1 repairs. In our series twelve operations to close cranionasa1 fistulas were carried out on nine patients, Low bilateral fronta craniotomy w-as found to give adequate exposure. In cases of massive biIatera1 depressed skuI1 fracture the operation couId, in most instances, be performed through the skuI1 defect after remova of cornminuted fragments. DuraI defects were closed by the extradura1 approach when they Lay anterior to the cribriform pIate. This method [IO] was used because most often the dura couId be closed by direct siIk suturing after its mobiIization. DuraI defects, in or behind the cribriform pIate region, were usuaIIy closed by wedging a piece of muscIe in the crania1 defect and the paranasa1 sinus and then appIying a generous piece of fascia Iata or temporaIis fascia intraduraIIy over the meningea1 defect. In most instances a few guy sutures were pIaced at the corners of the graft. It was considered necessary to use muscle beneath the piece of fascia because in two patients who required reoperation the graft had disappeared. One patient required reoperation because of the faifure of gelfoam to sea1 the duraf defect; this was the onIy patient in whom this method of repair was used. The intradura1 exposure is usuaIIy quicker, facifitates discfosure of a cranionasa1 fistuIa and aids in the protection of the bIood suppfy of herniated cortex. In cases of missiIe wounds near the anterior fossa, the anterior fossa floor should be inspected intraduraIIy in addition to 523
in Anterior
Fossa
the dkbridement of buIIet tracts. The intradural approach can be undertaken on the first day of injury, but after the first day and throughout the following week it becomes a diffIcuIt procedure because of edema of the frontal lobes. A reparative procedure shouId not be performed in the presence of meningitis, abscess or other infection. Of the nine patients treated operatively, four had repair on the day of injury, three hacf repair ten to eighteen days after’injury, one after four months and one after four years. The Iatter two patients had delayed cerebrospinal fluid rhinorrhea. No appreciabIe difference in the postoperative course could be detected between those having repair on the day of injury and those repaired ten to eighteen days Iater. In most patients rhinorrhea had ceased by the second postoperative day, but in one it persisted untif the fifth dav. Two patients had a striking improvement In their neurologic status immediately after operation. In both of them sizabIe amounts of subfrontal cIot and puIpified tissue were removed. There were no fataIities from repair of cranionasaf fistuIas. Three patients required reoperation for recurrence of cerebrospina1 fIuid rhinorrhea. The first patient was reopened ten davs after the initia1 repair, and a second commu&cation, which had previousIy been overIooked, was found Ieading into the sphenoida1 sinus. When the second patient was reopened eighteen days after operation, it was noted that the geIfoam sponge had disappeared. When the wouncl of the third patient was reopened thirty-nine days after injury, the smaIIer and more posterior of two cranionasaf communications was stiff patent aIthough the smaI1 fascia1 graft had disappeared. Subsequently a11 three patients had healing without further recurrence of their cerebrospinal fI uid rhinorrhea. In Germany postoperative observations were confined to two months in a11 cases except two, since a11 patients were then returned to the Zone of the Interior. The patients at Wadsworth General HospitaI have been foIIowed up from six months to one year. SUMMARY
The resuIts of injury to the anterior fossa of the skuI1 are discussed, with particufar reference to the type of fracture encountered. A series of twenty-two cases of cranionasaf fistuIas, in which nine patients were operated
CrandaII 3. HOLBOURN, A. H. S. Mechanics of head injurv. , ” Lancet, 2: 438-441, 1943. 4. ADSON, A. W. CerebrospinaI rhinorrhea. Surgical repair of craniosinus fistula. Ann. Surg., 114:
upon, is presented. Of those patients operated upon for repair of fistuIas, there were no deaths or increase of neuroIogic deficit. Three patients required two operations each before successfu1 closure was obtained. The mechanisms of injury, cIinica1 manifestations and treatment for these injuries are reviewed. In brief, the indications for operative intervention are: (I) compound depressed frontal fractures; (2) extensiveIy cornminuted fractures of the anterior fossa; (3) increasing or (4) wideIy fissured persistent pneumocephaIus; fractures of the anterior fossa accompanied with rhinorrhea; (5) recurrent cerebrospina1 Auid rhinorrhea; and (6) episodes of acute or chronic meningitis associated with demonstrabIe paranasal sinus bony defect. The advisabiIity of extending these indications to incIude any case of rhinorrhea of earIy or Iate development is considered. It is emphasized that a craniosinus fktuIa may exist without obvious signs of rhinorrhea or intracrania1 air. Characteristic injury shouId caI1 for proper roentgenographic examination.
697, ‘941. 5. CAIRNS, H. and LEWIN, W. Fractures of the sphenoida1 sinus with cerebrospinal rhinorrhea. hit. M. J., I: I, 1951. 6. CLOWARD, R. B. and-CUNNINGHAM, E. B. The use of gelatin sponge in prevention and treatment of cerebrospina1 rhinorrhea. J. Neurosurg., 4: 519. 1947. 7. GUSHING, H. Experiences with orbito-ethmoida1 osteomata, having intracranial complications. Surg., Gynec., &- Obst., 44: 721, 1927. 8. DANDY, W. E. Pneumoccphalus. Arch. Surg., 12: 949, 1926. 9. Idem. Treatment of rhinorrhea and otorrhea. Arch. Surg., 49: 75, 1944. 10. GERMAN, W. J. Cerebrospinal rhinorrhe;l-surgical repair. J. Neurosurg., I : 60, 1944. I I. GISSANE, W. and RANK, B. K. Post-traumatic cerebrospinal rhinorrhea, with case report. Brit. J. Surg., 24: 717, 1939. 12. GURDJIAN, E. S. and WEBSTER, J. E. SurgicaI management of compound depressed fracture of fronta sinus. cerebrosoinaI rhinorrhea and pneumocephaIus: Arch. Otolaryng., 39: 287, 1944. 13. JOHNSON, R. T. and DUTT, P. On dural laceration over paranasal and petrous air sinuses. Brit. J. Surg. (War Surg. Supp.), I: 141, 1947. 14. LEWIN, W. Cerebrospinal rhinorrhea in cIosed head injuries. Brit. J. Surg., 42: 1, 1954. 15. RAND, C. W. Traumatic pneumocephalus-report of eight cases. Arch. Surg., 20: 935, 1930. 16. RIZZOLI, H. V., HAYES, G. J. and STEELMAN, H. F. Rhinorrhea and pneumocephaIus. J. Neurosurg., I r : 277, ‘954.
REFERENCES 1. GURDJIAN, E.
S., WEBSTER, E. S. and LISSNER. H. R. Biomechanics: Fractures, SkuII MedicaI Physics, voI. 2, pp. 99-105. Chicago, 1950. Year Book Publishers, Inc. 2. PUDENZ, R. H. and SHELDEX, C. H. The Iucite caIvarium-a method of direct observation. J. Neurosurg., 3: 487-505, 1946.
524
From the Department of Surgery, University oj Calijornia Medical Center, Los Angeles; and tbe Wadsworth General Hospital, Veterans Administration Center, Los Angeles, California.
is apparent that the anterior fossa of the skuI1 is the most vulnerable region for fracturing and contaminating injury in craniocerebra1 trauma. Although antibiotics have allowed the surgeon a greater Iatitude in treatment, nevertheIess a communication between the nasopharynx and intracranial contents remains a dangerous condition. Even though the immediate infection is controIled, the surgeon may still be confronted with the problem of recurrent bouts of serious iIlness. The probIem is IargeIy soIved if the condition is soon recognized and the communication properI? and effectiveIy seaIed during the acute stage of head injury. This articIe presents an anaIysis of twentytwo cases of cranial defects in the anterior fossa. Eighteen patients were encountered and treated by the author at the 97th General HospitaI, Frankfurt, Germany, between October 1952 and June 1954, whiIe four patients were seen from August 1954 to August rggg at the Wadsworth Genera1 HospitaI, Veterans Administration Center, Los AngeIes, CaIifornia. AI1 cases were traumatic in origin, demonstrating either cerebrospinal fluid rhinorrhea, intracrania1 air, or at operation fractures into the paranasal sinuses with meningea1 tears in the anterior fossa floor.
I
T
MECHANISMS OF INJURY In any head injury three effects are transmitted from the applied force: (I) the deformation of the skuI1 with or without fracture, (2) the rotation of the brain within the calvarium, and (3) the deveIopment of compressiona or
in
Culijornia
“rarefactional” strains within the brain along the direction of the appIied force. Deformation of the skuI1 depends on the veIocity of the impact and the size and shape of the striking object. The tensile strength varies with the age, sex and race of the patient. Studies by Gurdjian, Webster, and Lissner [I] have shown that a high velocity bIunt object causes Iocal circumscribed fracture and depression. Low velocity blunt impact causes an area of inbending at point of impact and, at considerable distance, an area of outbending in which a Iinear fracture may form. The linear fracture propagates both toward the point of the blow and in the opposite direction. Rotation effects are greatest in producing laceration or tearing of bIood vessels and occur wherever contour of the skuI1 permits gIiding of the brain, i.e., parietal and occipita1 regions [2]. In force applied to the fronta regions, the contour of the anterior fossa ffoor, the sphenoid ridge and the faIx cerebri Iimits this rotation so that shear strains onIy are produced in most instances. In the opinion of Holbourn [?I, the compressiona1 or rarefactiona1 strains are not thought to be especiaIIy injurious. Therefore, in direct frontal injuries it is the fracturing of the skuI1 and the shear strains within the Iobes which are of most importance. My observations are mainly directed to the mechanisms of fracturing and subsequent contamination. It is obvious from the foregoing that anatomic features also infIuence the fractures which are produced. In the base of the skuI1 and proIonged up into the vauIt are the buttresses of the sphenoid ridge, and aIong the former metopic suture. The supraorbita1 ridges form a horizontal arch. A linear fracture at a right angIe to a buttress wiII pass through, but at
CrandalI fragments in the ethmoid roof seem to disappear and leave an almost oval-shaped aperture \vitll lacerated dura overlying. One additional factor ma>. be important in the production of fractures. The tough, inelastic falx attaches to the crista galli, and in depressed fractures stretching the falx ma>. wrench the ethmoicl bone ancl its connections. 1 have found that the fractures of the anterior fossa floor which result in craniosinus fistula deveIop from several sources. They may be the result of linear fractures radiating from the vault, from depressed fracture low on the vault, from facial injury or from force directed at the base of the skull. For convenience 1 have divided them into four groups. FRONTAL
FIG. I. TrnnsiIlumination of dried skuI1, displaying the buttresses and ridges of bone with relation to thr p:uxnasaI sinuses.
other angles \vill be diverted to run paraIle1 to it. The structure of the anterior fossa floor is such as to predispose it to isolated fractures. (Fig. I.) The thin bone of the floor is irregular in contour and thickness due to the convoIutional markings. Inset is the depression of the cribriform plate with the delicately waIIed ethmoid cehs at each side and the larger frontal and sphenoida1 sinuses before and behind. Extending IateraIIy from the central region are two ridges of greater bony density; one into the orbital roof and the other at the IeveI of the posterior crihriform plate. These ridges of heavier bone may defIect a radiating fracture and turn it inward to these sinuses. The second unique characteristic of this region is the type of bone. The convoIutiona1 markings resuIt in several small eminences with thicker bone at the apex surrounded by thinner bone. The most prominent of these eminences form the roofs of the ethmoid ceIIs. A fissure wiI1 tend to run through the thinner bone around such an eminence, resuIting in a free fragment of bone. Not uncommonly, we have found that the
INJURIES
Nine patients suffered extensive injury with depressed fronta bone fragments, comminuted fractures of the paranasa1 sinuses and orbita roofs, and open fronta scaIp wounds. Two cases of an unusua1 nature were the resuIt of accidents in which soldiers were struck by a tire rim while inAating a truck tire under great pressure. Both injuries were identica1 in that large, bilateral depressed fronta fractures at the supraorbita1 IeveI were produced. The remaining cases arose from more common accidents, and most of them incIuded varying degrees of damage to the eyes. Immediate operation was undertaken in seven patients to repair extensive meningea1 tears. Such tears were frequently associated with moderateIy Iarge bony defects over the ethmoid sinuses and cribriform pIate. In two patients very Iarge defects in the sphenoid sinuses existed. Herniations of brain tissue aImost invariabIy accompanied such large defects. OnIy one instance of a simpIe Iinear fracture in the fronta region was encountered; the fracture passed through the right fronta sinus and radiated back into the ethmoid ceIIs. A pneumatoceIe was visibIe on the initia1 fiIms. TEMPORAL
FRACTURES
The presence of midIine crania1 and meningea1 defects may not be recognized in the instance of tempora1 fractures. The fracture may run in an arc-Iike fashion across the floor of the anterior fossa, resuIting in comminuted fractures in the roof of the paranasa1 sinuses. ParticuIar attention shouId be paid to this
Post-traumatic
Cranial
Defects
in Anterior
Fossa
midline complication of temporal fractures, and for this reason two case reports are appended. Six instances of temporoparietal fracture with craniosinus fistula were encountered. CASE I. A thirty-one year old white sergeant \vas found dead in his bed at 5:40 A.X on January 22, ‘954. Review of his past records revealed that in Korea, September, 1950, he had sustained a left, compound, frontotemporat skull injury that resulted in multiple foreign bodies in the left frontal lobe. Surgical removal of bone in this area was performed shortly thereafter. In November, 1950, he was treated for meningitis (alpha streptococcus), and in the spring of 1953 at a U.S. Genera1 Hospital a tantalum craniopIasty was performed to fill the left frontotemporal skuII defect. The pertinent autopsy findings incIuded a skull region defect, 5 by 3 cm., in the Iower temporal filled by a perforated metaIIic pIate. Another bony defect, 1.5 cm. in diameter, Iay in front of the cribriform pIate and communicated with the left frontal sinus in front and the ethmoid ceIIs behind. A third defect, 2 cm. in diameter, crossed the right orbita plate; the dura and overIying brain were adherent in this region. (Fig. 2.) was An irregular abscess, 6 cm. in diameter, found in the right fronta pole. It was hIIed with thick, green pus; the organism was cultured as pneumococcus. The overlying she11 of cerebral substances was thin, friable and markedIy adherent to the dura and defects at the base of the skull. Purulent exudate filled the subarachnoid spaces. The ependyma1 lining of the right ventricle was partiaily ulcerated and contained inflammatory exudate. Widespread toxemia was manifested by hemorrhages in the lungs, epicardium and skin; pneumococcus was aIso recovered from the bIood and pericardial fluid.
FIG. 2. Case I. Aboue: A Iarge cranial defect is present in the roofs of the anterior ethmoida1 ceIIs. Note also the tantalum pIate in the left temporal region. Below: The brain shows a right frontat abscess which extends across the midline and involves the Ieft frontat poIe as well.
there were many radiating fractures. At no time did he have any cerebrospinal rhinorrhea. ShortIy after admission both frontal lobe tracts were debrided and numerous pieces of bone, cIot and gunpowder were removed. A tracheotomy was performed and blood was administered. Fifteen days after injury anuria supcrvencd, and the patient died eighteen days after admission. Autopsy revealed muItipIe puImonary emboli, phIebothrombosis of the tibia1 veins, lower nephron nephrosis and a small, indurated duodenal ulcer. In addition to the skuI1 defects aIready described, an irregular corona1 fracture at the base of the skull extended between these two defects and invoIved the cribriform plate and the upper surface of the sphenoidal sinus, aIlowing a direct communication with the intracrania1 contents. A probe could be passed into the sinus and the nasal fossa. The undersurfaces of the fronta lobes were irregularly lacerated, with protrusion of the parenchyma into the right sphenoida1 sinus. No
CASE II. On March 7, 1954, at 10:35 P.M., a twenty-three year old Negro Air Force policeman was found unconscious behind his overturned jeep with a missiIe wound of the head. When admitted to the hospital he was in profound coma and shock, and had spasmodic, irregular respirations. Examination revealed punctate missile wounds in each temple. The right wound, which was filled with black gunpowder, was located 2 cm. behind the outer edge of the eyebrow. The left exit wound was at the hairline approximately 3 cm. above the zygomatic arch. There was bleeding from both nostrils, slight exophthalmos and a considerabIe sweIIing beneath the scaIp on both sides. The right pupil was wideIy diIated and fixed. The patient moved all extremities well. He was treated for shock, and roentgenograms of the skuI1 reveaIed rounded defects in both tempora1 areas from which 519
CrandaII Roentgenograms revealed fractures confined to the shell-like bones of both sides of the maxiIIa and sinuses. The IateraI limits of this block-Iike fragment could be seen cIearIy by fracture-separation of the zygomatic arches. LittIe or no radiation of the fractures into the supraorbital ridge was seen. The exact status of fractures within the facia1 bones is often diffIcuIt to determine. DISCRETE
FRACTURES
In this series at Ieast one case appeared to faI1 into this group of isoIated small fractures in the anterior fossa floor. CASE III. A twenty-eight year old corporal suffered from intermittent rhinorrhea caused by a severe head injury sustained in Korea in 1951. He had five attacks of meningitis, one of which was folIowed by right hemiplegia and aphasia. After craniotomy with attempted closure of the dura was undertaken in a U.S. Genera1 Hospital, the patient was free of rhinorrhea for severat months. Reoperation was undertaken at the 97th General Hospital Frankfurt, Germany, following his Iast episode of meningitis in May, 1954. A bony defect in an ethmoid roof was found and repaired. Adson [4] reported one case of a man who sustained a depressed skuI1 fracture at the vertex from the fall of a So-pound weight and who aIso had a discrete fracture of the anterior fossa ffoor.
FIG. 3. Case II. Above: Film shows a Iarge, bifrontal
fissure fracture and postoperative crania1 defect in the Ieft ternDora region. Note the marked tiItine of the crista gaili to the right. Below: Note biIatera1 ithmoid cell defects associated with the arc-like fracture of the anterior fossa floor.
CLINICAL
evidence of infection was found, although from the sinuses had exuded into the cavities. (Fig. 3.)
The principa1 manifestation of craniosinus communication is cerebrospina1 fluid rhinorrhea; of the twenty-two cases in this series, it was present in fourteen. Immediately after injury the rhinorrhea is a thin, bIoody fluid which becomes pink in one day and Iater is coIorIess and watery. The sugar content of the fluid was occasionaIIy heIpfu1 in identifying it as cerebrospina1 fluid. To avoid overIooking rhinorrhea and as a part of a physica examination, a11 unconscious or irrationa1 patients should be pIaced for a few minutes in the prone position with their faces dependent over the side of the bed. Ecchymoses, fluctuant sweIIings about the orbit and proptoses are aIso significant findings. These signs were noted in thirteen patients of the series. Nuchal rigidity (not attributabIe to meningitis, subarachnoid bIood, or injury to the neck) was often present, particuIarIy in those
mucus cranial
Comment on Case II. In this patient a massive defect existed without apparent rhinorrhea, and one which wouId have resuIted in compIications had not the aforementioned defects intervened. In retrospect, the anterior fossa ffoor wouId have been inspected and managed had the condition been suspected. Adequate, early x-rays are required even if anesthesia is necessary for a restIess patient. FACIAL
MANIFESTATIONS
INJURIES
Head-on bIows to the face may result in a bIock-Iike separation of the entire maxiIIa. The force is usuaIIy transmitted by the frontal process of the maxiIIa to the base of the anterior fossa. There were six such cases in this group.
52”
Post-traumatic
Crania1
Dlefects
in Anterior
Fossa
tions of air, and it is to this situation that I wish to caII specia1 attention. There were six such cases in this series. Since many forms of meningitis are now easiIy controIIed by various antibiotic drugs, it becomes important to consider the cause of the origina meningitis and, by radioIogic investigation, to determine if a fracture of the anterior fossa is present. In the foIIowing case the use of antibiotic drugs may we11 have actuahy fostered the deveIopment of chronic meningitis due to a fungus which may have gained ingress through default of other organisms.
patients with extensive damage at the base of the skuI1. It may be a valuabIe cIue to diagnosis. VisuaI heId defects from optic nerve invoIvement due to fracture of the optic foramen were found in seven cases. ExtraocuIar muscle involvement was present in eight cases. Three patients with massive frontal injury required enucleation for rupture of an eyeball. As in the instance of orbital fracture, injuries to orbital contents shouId Iead one to suspect nearby paranasal sinuses. Crepitation at the base of the nose usuaIIy indicates fracture of the nasa1 hones. In three cases, when the upper teeth were grasped, the whole block of maxiIIary bone couId be moved with ease and the contours of the face altered. No wiring could be done in the presence of the acute cerebral injury because of the difficulty of maintaining a good airway and the possibility of vomiting. After the rhinorrhea had spontaneously ceased, manipulation or wiring of the facia1 bones frequently resuIted in a temporary recurrence of the rhmorrhea. Despite the remarkable instability of the face, the fracture unions were firm in two to three weeks. As other authors [6,8] have pointed out, signs which are definitely indicative of a dural communication with the paranasal sinuses incIude aeroceles (flask-like collections in the frontal lobe substance) and pneumocephalus (collections of air in the ventricles or over the convexities via the subdura1 and subarachnoid spaces) [r~,r6]. Two such instances occurred in this series. Radiologic demonstration of the bony defect is of great importance. Stereoscopic posteroanterior views are heIpfu1 in tracing fissures. Tilting of the crista gaIli, as seen in Fig. 3, is sometimes observed. LateraI views that show buckling of the orbita roof and tiIting of the anterior clinoid process usuaIIy indicate defects in the ethmoid or sphenoida1 sinuses. Optic foramen views often help to show orbita fractures and some of the ethmoid ceIIs. Johnson and Dutt [r?] have deveIoped two projections, simiIar to the optic foramen view, that outline the ethmoid and sphenoida1 sinuses; the appearances are detaiIed in their articIe. These Iatter views, however, require excehent cooperation from the patient and the best radioIogic technic; even then they may be difficuIt to interpret. Craniosinus Fistulas Revealed Only by Meningitis. Craniosinus fistma can exist without cerebrospina1 rhinorrhea or intracrania1 cohec-
CASE IV. On December I I, 1954, a sixty-two year oId man was invoIved in an automobile accident, during which his head cracked against the windshieId. AIthough he sustained facial fractures, hemorrhage and a dislocated Iens in the right eye, and cornminuted fractures of the patella, he was not unconscious. Because of signs of infection in the eye, it was enucIeated. Shortly after admission to the Wadsworth General HospitaI on December 26th, radiographs of the skul1 showed fractures of the inferior rim of the orbit on the right, fractures of the nasa1 bones and a fracture of the posterior waI1 of the frontal sinus. From the time of injury the patient compIained of a constant miId headache, principalIy over the right fronta area. On March II, 1955, the patient was Iethargic, and during the next few days he had four episodes of nausea and vomiting, shaking chills and a temperature of 38.g’c. (102’F.). He aIso complained of increasing headaches. Lumbar puncture revealed a pressure of 160 mm. and 185 white ceIIs per cc., composed of 54 per cent poIymorphonucIear Ieukocytes and 46 per cent lymphocytes. During the remainder of the patient’s hospita1 course he ran a continuous Iow grade fever between 37.8’~. It was accompanied (I OO’F.) and 38.g”c. (I 02’F.). with a meningea1 cellular reaction averaging 300 white ceIIs per cc., the majority of which were poIymorphonucIear leukocytes. Total protein averaged 150 mg. per cent and gIobuIin 2 pIus. A total of fifteen cultures were made, six specifically for fungi; a11 were negative. Because of suspicion of brain abscess a ventriculogram was taken on ApriI 26th; it was entireIy negative. Antibiotic drugs were used from the time of the accident to the patient’s death, except for a period from February 9th to March I 7th. The patient was treated with various combinations of penicillin, sulfadiazine, erythromycin, chloramphenicol, tetracycline and oxytetracycline hydrochIoride. None of these agents affected his cIinica1 course, nor did they aIter the ceIIuIar reaction in the spina fluid. In JuIy increasing Iethargy and, at times, stupor
521
CrandalI fractures in the anterior fossa accompanied with rhinorrhea; (5) recurrent cerebrospinal rhinorrhea or recurrent bouts of meningitis. The question now arises as to jvhether (6) cerebrospinal rhinorrhea beginning at the time of injury is an indication for immediate intervention, and if not, just how long it should be aIlowed to persist before becoming one. Arbitrary limits have been set by certain authors according to their experience. Adson [d] allowed the condition to persist eight, weeks [9] two before undertaking repair, Dandy weeks, days
and
and complete disorientation developed. He had tremor which was irregular, coarse and charactcrized by some slight rigidity of a cogwhee1 nature and a slight motor restlessness in all extremities. On July 7th a second ventricuIogram reveaIed extremely thickened and greenish arachnoidal membranes and a very marked diIatation of the entire ventricuIar system. The patient died six months and twenty-seven days after injury. Autopsy examination disclosed that the calvarium was free of osseous abnormality except for the right ethmoid sinus. The brain in the inferior right frontal area adjacent to the defect showed a 1.3 cm. Iocalized area of herniation and mild softening where the brain parenchyma and oIfactory tract had protruded into the osseous defect. (Fig. 4.) There was a smaI1 quantity of moderately cIoudy seropurulent exudate over the base of the brain and the inferior right fronta herniation. A Ieft intracerebral hemorrhage in a ventricular needle tract was present. The basilar meninges were thick and encrusted with puruIent material, especially around the cerebeIIopontiIe angIe, interpeduncuIar space and the foramens of Luschka. Microscopic examination showed active chronic meningitis in the base of the brain incIuding foreign body giant ceII reaction and septated chIamydospore-forming organisms, probably aspcrgillosis. TREATMENT
In certain instances indications for operative intervention are obvious: (I) compound de(2) extensiveIy compressed fronta fractures; minuted
fractures
increasing
these
or
should
of
the
persistent
be
added:
anterior
fossa;
pneumocephaIus.
(4)
widely
(3) To
fissured 522
and
Webster
[12]
a “fe\\
the Radcliffe Inthat “Dural repair shouId be considered in al1 cases of paranasaI sinus fracture with rhinorrhea, whether it is of earIy or late onset., of brief or long duration.” This conclusion is based on a foIIow-up study varying from three to nine years. He followed up simiIar groups of cases in which no surgery was performed. CompIications of operation were aImost ni1, whiIe cases in which there was no surgery had a high incidence of Iate infections, recurrent rhinorrhea and mortaIity. In the present series certain observations in favor of Lewin’s conclusions were made. In those patients operated upon from ten days to four months after injury the natural processes of repair as observed at operation were deficient. Herniations of cerebra1 tissue with piarachnoidal adhesions to the dura mater at the edge of the defect were common findings. A web-like arachnoidal membrane over the defect was also frequentIy encountered. Previous meningitis did not seem to have increased the reparative process. It seems that the only instance in which successfu1 natural repair can be expected is that in which the dural edges are in contact without the interposition or interference of other tissue (i.e., bony spicules, mucous membranes, brain, and so forth). In any case of recurrence of rhinorrhea or meningitis, as we11 as in any case of widely fissured fracture, this idea1 natural approximation is not present. On the other hand, it was possible to perform the operative repairs without added neuroIogic deficit and, in most cases, with improvement. in the neurologic state. The principIes of cIosure of cranionasal f%tuIa have gradually evolved since 1927 when Cushing [7] reported the use of free fascia Iata grafts in patients from whom he had removed RecentIy
FIG. 4. Case III. Photomicrograph showing a pedunculated herniation of brain tissue with a centra1 core of malacia surrounded by marked gliosis. At autopsy the protrusion was through an osseous defect communicating with the right ethmoid sinus. OriginaI magnification, x6.
Gurdjian
only.”
firmary,
Lewin
Oxford,
[14],
concluded
at
Post-traumatic
Crania1
Defects
ethmoid exostoses. In 1926 Dandy [8] cIaimed to be the first to close a fistufa successfuIIv in a patient with spontaneous cerebrospinal rhinorrhea. Various materials have been used h,y different surgeons; bone wax and strips of muscle in the defect, temporalis fascia, tibia1 fascia Iata, periosteaf grafts [r I], pericranium, an d gelfoam@ sponge [6]. The extradura1 approach was almost universaIIy used unti1 Cairns and Lewin [r] used the intradural approach in treating sphenoidal sinus fractures with fistufas. A defect so far posterior required the intraduraf approach; it was also found easier and the resuIts of free facial grafting were equaIIy as good. SubsequentIy, during WorId War II British surgeons under the inAuence of Cairns used this method excIusiveIy and wideIy in treating missiIe wounds with cranionasal fistuIas, with exceIIent resuIts. In 1944 Gurdjian and Webster [12] recommended combined extradura1 and intradura1 repairs. In our series twelve operations to close cranionasa1 fistulas were carried out on nine patients, Low bilateral fronta craniotomy w-as found to give adequate exposure. In cases of massive biIatera1 depressed skuI1 fracture the operation couId, in most instances, be performed through the skuI1 defect after remova of cornminuted fragments. DuraI defects were closed by the extradura1 approach when they Lay anterior to the cribriform pIate. This method [IO] was used because most often the dura couId be closed by direct siIk suturing after its mobiIization. DuraI defects, in or behind the cribriform pIate region, were usuaIIy closed by wedging a piece of muscIe in the crania1 defect and the paranasa1 sinus and then appIying a generous piece of fascia Iata or temporaIis fascia intraduraIIy over the meningea1 defect. In most instances a few guy sutures were pIaced at the corners of the graft. It was considered necessary to use muscle beneath the piece of fascia because in two patients who required reoperation the graft had disappeared. One patient required reoperation because of the faifure of gelfoam to sea1 the duraf defect; this was the onIy patient in whom this method of repair was used. The intradura1 exposure is usuaIIy quicker, facifitates discfosure of a cranionasa1 fistuIa and aids in the protection of the bIood suppfy of herniated cortex. In cases of missiIe wounds near the anterior fossa, the anterior fossa floor should be inspected intraduraIIy in addition to 523
in Anterior
Fossa
the dkbridement of buIIet tracts. The intradural approach can be undertaken on the first day of injury, but after the first day and throughout the following week it becomes a diffIcuIt procedure because of edema of the frontal lobes. A reparative procedure shouId not be performed in the presence of meningitis, abscess or other infection. Of the nine patients treated operatively, four had repair on the day of injury, three hacf repair ten to eighteen days after’injury, one after four months and one after four years. The Iatter two patients had delayed cerebrospinal fluid rhinorrhea. No appreciabIe difference in the postoperative course could be detected between those having repair on the day of injury and those repaired ten to eighteen days Iater. In most patients rhinorrhea had ceased by the second postoperative day, but in one it persisted untif the fifth dav. Two patients had a striking improvement In their neurologic status immediately after operation. In both of them sizabIe amounts of subfrontal cIot and puIpified tissue were removed. There were no fataIities from repair of cranionasaf fistuIas. Three patients required reoperation for recurrence of cerebrospina1 fIuid rhinorrhea. The first patient was reopened ten davs after the initia1 repair, and a second commu&cation, which had previousIy been overIooked, was found Ieading into the sphenoida1 sinus. When the second patient was reopened eighteen days after operation, it was noted that the geIfoam sponge had disappeared. When the wouncl of the third patient was reopened thirty-nine days after injury, the smaIIer and more posterior of two cranionasaf communications was stiff patent aIthough the smaI1 fascia1 graft had disappeared. Subsequently a11 three patients had healing without further recurrence of their cerebrospinal fI uid rhinorrhea. In Germany postoperative observations were confined to two months in a11 cases except two, since a11 patients were then returned to the Zone of the Interior. The patients at Wadsworth General HospitaI have been foIIowed up from six months to one year. SUMMARY
The resuIts of injury to the anterior fossa of the skuI1 are discussed, with particufar reference to the type of fracture encountered. A series of twenty-two cases of cranionasaf fistuIas, in which nine patients were operated
CrandaII 3. HOLBOURN, A. H. S. Mechanics of head injurv. , ” Lancet, 2: 438-441, 1943. 4. ADSON, A. W. CerebrospinaI rhinorrhea. Surgical repair of craniosinus fistula. Ann. Surg., 114:
upon, is presented. Of those patients operated upon for repair of fistuIas, there were no deaths or increase of neuroIogic deficit. Three patients required two operations each before successfu1 closure was obtained. The mechanisms of injury, cIinica1 manifestations and treatment for these injuries are reviewed. In brief, the indications for operative intervention are: (I) compound depressed frontal fractures; (2) extensiveIy cornminuted fractures of the anterior fossa; (3) increasing or (4) wideIy fissured persistent pneumocephaIus; fractures of the anterior fossa accompanied with rhinorrhea; (5) recurrent cerebrospina1 Auid rhinorrhea; and (6) episodes of acute or chronic meningitis associated with demonstrabIe paranasal sinus bony defect. The advisabiIity of extending these indications to incIude any case of rhinorrhea of earIy or Iate development is considered. It is emphasized that a craniosinus fktuIa may exist without obvious signs of rhinorrhea or intracrania1 air. Characteristic injury shouId caI1 for proper roentgenographic examination.
697, ‘941. 5. CAIRNS, H. and LEWIN, W. Fractures of the sphenoida1 sinus with cerebrospinal rhinorrhea. hit. M. J., I: I, 1951. 6. CLOWARD, R. B. and-CUNNINGHAM, E. B. The use of gelatin sponge in prevention and treatment of cerebrospina1 rhinorrhea. J. Neurosurg., 4: 519. 1947. 7. GUSHING, H. Experiences with orbito-ethmoida1 osteomata, having intracranial complications. Surg., Gynec., &- Obst., 44: 721, 1927. 8. DANDY, W. E. Pneumoccphalus. Arch. Surg., 12: 949, 1926. 9. Idem. Treatment of rhinorrhea and otorrhea. Arch. Surg., 49: 75, 1944. 10. GERMAN, W. J. Cerebrospinal rhinorrhe;l-surgical repair. J. Neurosurg., I : 60, 1944. I I. GISSANE, W. and RANK, B. K. Post-traumatic cerebrospinal rhinorrhea, with case report. Brit. J. Surg., 24: 717, 1939. 12. GURDJIAN, E. S. and WEBSTER, J. E. SurgicaI management of compound depressed fracture of fronta sinus. cerebrosoinaI rhinorrhea and pneumocephaIus: Arch. Otolaryng., 39: 287, 1944. 13. JOHNSON, R. T. and DUTT, P. On dural laceration over paranasal and petrous air sinuses. Brit. J. Surg. (War Surg. Supp.), I: 141, 1947. 14. LEWIN, W. Cerebrospinal rhinorrhea in cIosed head injuries. Brit. J. Surg., 42: 1, 1954. 15. RAND, C. W. Traumatic pneumocephalus-report of eight cases. Arch. Surg., 20: 935, 1930. 16. RIZZOLI, H. V., HAYES, G. J. and STEELMAN, H. F. Rhinorrhea and pneumocephaIus. J. Neurosurg., I r : 277, ‘954.
REFERENCES 1. GURDJIAN, E.
S., WEBSTER, E. S. and LISSNER. H. R. Biomechanics: Fractures, SkuII MedicaI Physics, voI. 2, pp. 99-105. Chicago, 1950. Year Book Publishers, Inc. 2. PUDENZ, R. H. and SHELDEX, C. H. The Iucite caIvarium-a method of direct observation. J. Neurosurg., 3: 487-505, 1946.
524