Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.

OBJECTIVE: To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture. METHODS: We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014. RESULTS: A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis. CONCLUSIONS: This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Basilar skull fractures: the petrous bone.

Basilar skullfractures: the petrous bone. OBJECTIVES: to provide suggestions for the management of three of the most dangerous or important lesions (internal carotid artery lesions, cerebrospinal fluid leaks and facial nerve paralysis) associated with the petrous part of basilar skull fractures, thereby trying to assess categories of evidence and determine strengths of recommendation. METHODOLOGY: A PubMed-based literature review was carried out, as well as a consultation of online sources as encountered in the literature review. Also, a non-systematic search of chapters of well-known books dealing with the subject of temporal bone traumata was conducted. RESULTS: Specific levels of evidence and/or strength of recommendation can be retrieved from the literature, but only with respect to the prophylactic use of antibiotics, the prescription of antithrombotic medications and the indications for angiography. CONCLUSION: The ample amount of available literature allows for sound management decisions, with reference made to algorithms when available in the literature. Nevertheless, for most of the management/search questions, categories of evidence and strength of recommendation are low or lacking.

Defining pediatric orbital roof fractures: patterns, sequelae, and indications for operation.

BACKGROUND: There are few published data addressing pediatric orbital roof fractures, particularly regarding long-term outcomes and indications for operative intervention. To provide evidence-based guidelines for the management of these injuries, the authors examined a large cohort of patients with this injury pattern. METHODS: Institutional review board approval was obtained to review pediatric patients presenting to Johns Hopkins Hospital from 1991 to 2011. All patients with a diagnosis indicating orbital or skull base fractures were reviewed to determine orbital roof involvement. Patients with roof fractures were assessed for demographics, management, and outcomes. RESULTS: A total of 1484 pediatric patients carried the diagnoses of orbital fracture or anterior skull base fracture. After review, 159 patients (11 percent) were found to have true orbital roof fractures, with 36 percent being comminuted. One hundred five patients returned after discharge (average follow-up, 19 months). One patient developed vertical dystopia 10 months after being lost to follow-up with a large, comminuted fracture. Ten patients underwent surgery to repair the orbital roof. Inferior displacement correlated with need for surgical repair (p < 0.001). CONCLUSIONS: In the largest study to date analyzing pediatric orbital roof fractures, the authors found that most can be managed conservatively with good long-term outcomes. Vertical dystopia occurred in less than 1 percent of patients and was associated with large, comminuted fractures. Inferiorly displaced and fractures with a surface area over 2 cm represent higher risk fractures that should be followed closely for possible intervention based on the development of sequelae such as vertical dystopia or encephalocele. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak.

OBJECTIVE: To determine rates of cerebrospinal fluid (CSF) leak, meningitis, and readmission in pediatric and adult patients with isolated basilar skull fracture. STUDY DESIGN: Cross-sectional analysis of a statewide database. SUBJECTS: Patients with isolated basilar skull fracture (1995-2010). METHODS: Patients were identified within the California Office of Statewide Health Planning and Development database using ICD-9 diagnosis codes. RESULTS: A total of 3563 pediatric and 10,761 adult patients met inclusion criteria. In-hospital rates of meningitis (0.48% and 0.64%, P = .3360) and CSF leak (2.33% and 1.75%, P = .0270) were similar among children and adults, respectively. Rates of 90-day meningitis (0.17% and 0.37%, P = .0714) and CSF leak (0.40% and 0.40%, P = .9823) were also similar. Thirty-day readmission was 4.6% for children compared with 12.4% for adults (P < .001). For both pediatric and adult patients, extra-axial hematoma (odds ratio [OR] [confidence interval {CI}] 1.65 [1.05-2.59] and 1.61 [1.34-1.95]) and comorbidities (OR [CI] 2.19 [1.11-4.34] and 1.28 [1.04-1.59]) were associated with significant increases in 30-day readmission. Loss of consciousness greater than 1 hour (OR, 3.05; 95% CI, 1.53-6.08) and CSF leak (OR, 3.28; 95% CI, 1.41-7.64) increased the likelihood of pediatric readmissions. Lack of insurance (OR, 0.67; 95% CI, 0.50-0.90) and female gender (OR 0.83; 95% CI, 0.70-0.99) reduced the likelihood of adult readmission. CONCLUSION: Meningitis and CSF leak following isolated basilar skull fractures are uncommon. Readmission within 30 days was more common in adults than in children. CSF leak, hematoma, and prolonged loss of consciousness increased the likelihood of readmission in children. Intracranial injury, male gender, having insurance, and comorbidities increased the likelihood of readmission in adults.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures.

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.

Nonoperative treatment of occipital condyle fractures: an outcomes review of 32 fractures.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To evaluate the outcomes of patients with occipital condyle fractures (OCFs) treated nonoperatively and establish factors associated with neck disability. SUMMARY OF BACKGROUND DATA: The majority of OCFs are treated nonoperatively; however, few studies have reported long-term functional outcomes of these patients. METHODS: From 1999 to 2007, 103 patients with OCFs were identified. Of this cohort, 28 patients with 32 fractures met the inclusion criteria. Fracture and patient characteristics, including patient age and sex, Anderson and Montesano fracture type, bilaterality, associated head injury, and fracture displacement, were noted. The Neck Disability Index (NDI) was calculated at final follow-up. RESULTS: Anderson and Montesano type III fractures were the most commonly observed (54%), followed by type II (43%). The mean NDI was 14.0, which correlates with mild disability, and the NDI headache question showed the highest mean disability score of all questions. There was no statistically significant association between NDI scores and fracture type, displacement of fracture, sex, bilaterality, or presence of head injury. Age was associated with NDI scores, with age range of 40 to 60 years having a mean NDI score of 24.3. CONCLUSION: Anderson and Montessano types I, II, and III OCFs may be treated nonoperatively in the absence of ligamentous instability and concomitant cervical injuries with the expectation of mild neck disability regardless of the displacement, bilaterality, sex, or presence of head injury. Greater disability may be expected in patients aged between 40 and 60 years than in other ages.

Isolated bilateral zygomatic arch fractures of the facial skeleton are associated with skull base fractures.

BACKGROUND: To date, only limited case reports involving isolated bilateral zygomatic arch fractures exist. This fracture pattern is defined by the presence of bilateral zygomatic arch fractures and the absence of any other facial fractures. The purpose of this study was to systematically review a large trauma database to determine whether this fracture pattern exists and, if so, to elucidate the mechanism of injury and associated concomitant injuries. METHODS: A retrospective review of all patients admitted to the R Adams Cowley Shock Trauma center from February of 1998 to December of 2009 was conducted. International Classification of Diseases, Ninth Revision coding of computed tomographic scans was used to identify patients with zygoma fractures. The facial computed tomographic scans of all patients coded with bilateral zygoma fractures were reviewed to determine whether any had isolated bilateral zygomatic arch fractures. Medical charts were reviewed extensively. RESULTS: Five patients (0.24 percent of all zygoma fractures, 3.18 percent of bilateral zygoma fractures) were found to have isolated bilateral zygomatic arch fractures. All five patients had evidence of skull impact with at least one skull fracture and one skull base fracture. Glasgow Coma Scale scores (range, 6 to 14; average, 8.2) were significantly lower (t test, two-sided, p=0.01) compared with all patients (average, 12.2) with facial trauma during the study period. CONCLUSIONS: Isolated bilateral zygomatic arch fractures do exist. The authors' findings suggest skull impacts as the inciting mechanism of injury and an intimate link with skull base force transmission. The severe nature of this injury warrants a search for concomitant injuries to the head, brain, and spinal cord.

Occipital condyle fractures.

OBJECTIVE: The anatomy, clinical presentation, radiologic evaluation, treatment, and outcome of occipital condyle fractures are reviewed. METHODS: We review and discuss the literature on occipital condyle fractures. RESULTS: Occipital condyle fractures are best diagnosed with computed tomography. The neurologic presentation is variable. The majority of these injuries may be treated nonoperatively, but an occipitocervical fusion is necessary to restore stability across the craniovertebral junction. CONCLUSION: Occipital condyle fractures are a rare but serious injury that requires prompt diagnosis and treatment.

Use of nasogastric tubes in trauma patients--a review.

Traditionally, suspected basal skull fractures have been considered a relative contra-indication to inserting a nasogastric tube (NGT). In patients with basal skull fractures the Advanced Trauma Life Support protocol recommends that an orogastric tube (OGT) be inserted rather than a nasogastric tube (NGT). This article reviews the available literature. We conclude that in patients with suspected or confirmed basal skull fractures numerous case reports confirm that nasogastric tube insertion may lead to intracranial placement which, although the causal relationship is unclear, is associated with patient death.

Traumatic carotid cavernous fistula accompanying basilar skull fracture: a study on the incidence of traumatic carotid cavernous fistula in the patients with basilar skull fracture and the prognostic analysis about traumatic carotid cavernous fistula.

BACKGROUND: Traumatic carotid cavernous fistula (TCCF) is a rare vascular complication of traumatic brain and facial injury. The purpose of this study was to analyze the incidence of this disorder in different types of basilar skull fracture, determine whether particular clinical factors impacted outcomes, and discuss ways of improving prognosis. METHOD: We performed a retrospective analysis of cases with basilar skull fracture or angiography-confirmed TCCF in inpatients between 1999 and 2005, as well as an analysis of the incidence rate of TCCF in each type of basilar skull fracture. For patients diagnosed with TCCF, cases were divided into "disability" and "no disability" groups, and related clinical factors with potential impact on prognosis were analyzed. RESULTS: In 312 inpatients with basilar skull fractures, an overall incidence of 3.8% for TCCF was observed, and the incidence of this disorder with anterior fossa fracture, middle fossa fracture, and posterior fossa fracture was 2.4%, 8.3%, and 1.7%, respectively. In this retrospective analysis, factors such as patients' age, gender, number of embolization procedures performed, and time from injury to first symptom onset did not significantly affect outcome (p > 0.05). However, the time from first symptom onset to endovascular embolization differed significantly between the disability and no disability groups (p < 0.05). CONCLUSIONS: A relatively high incidence of TCCF occurred in patients with middle fossa fractures, especially those with transverse or oblique fractures. Prompt diagnosis and intervention should be emphasized in the management of patients with TCCF, and noninvasive techniques for early detection of TCCF should be considered in cases of middle fossa fractures under certain conditions after brain or facial trauma to ensure positive outcomes.

Bilateral traumatic abducens nerve palsy associated with skull base fracture--case report.

A 29-year-old man presented with skull base fractures involving the bilateral petrous bones and clivus to the posterior clinoid process manifesting as bilateral abducens nerves palsy. Conservative treatment resulted in residual bilateral abducens nerves palsy. Posterolateral impact probably resulted in strain-stress in the neighborhood of the foramen lacerum, resulting in a clivus fracture of the posterior clinoid process and bilateral petrous bone fractures. Chalasia of Gruber's ligament then exerted mechanical pressure on the bilateral abducens nerves.

Bone formation enhanced by implanted octacalcium phosphate involving conversion into Ca-deficient hydroxyapatite.

The present study was designed to investigate whether hydrolysis of synthetic octacalcium phosphate (OCP) into hydroxyapatite affects bone formation. Mouse bone marrow stromal ST-2 cells and primary calvarial osteoblastic cells were cultured on the dishes pre-coated with OCP or its hydrolyzed Ca-deficient hydroxyapatite (OCP hydrolyzate; HL). The capacity of proliferation and differentiation was determined up to day 20. Granules of OCP and HL were implanted into critical-size rat calvaria defects for 4 and 12 weeks, and then bone formation was measured by histomorphometry. Structural changes of incubated and implanted OCP were determined by X-ray diffraction (XRD) and Fourier transform infrared spectroscopy (FTIR). The proliferation of both ST-2 and primary osteoblasts cultured on OCP or HL was initially inhibited, whereas their differentiation to osteoblasts was promoted at last. Implantation of OCP in bone defect more significantly enhanced bone formation than that of HL until 12 weeks. OCP tended to convert to apatite in vitro and in vivo. The conversion of the implanted OCP was ascertained to advance gradually with implantation periods. Taken together, these results suggest that OCP supports appositional bone formation and OCP-apatite conversion may be involved in this stimulatory capacity of OCP.

Fracture of skull base with delayed multiple cranial nerve palsies.

This report describes a pediatric case of delayed glossopharyngeal nerve, vagus nerve, and facial nerve palsies after a head injury. Computed tomography scan of the skull base revealed the fracture of the petrous part of the temporal bone, and the fracture involved the tip of petrous pyramid, in front of the jugular foramen. The anatomical features, mechanisms, diagnosis, and treatment are discussed.

Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.

PURPOSE: The management of persistent, post-traumatic cerebrospinal fluid (CSF) rhinorrhea and otorrhea remains a surgical challenge. Repair of CSF leaks has evolved from that of an intracranial approach to one that is primarily extracranial and endoscopic. The purpose of this retrospective analysis is to determine the incidence of persistent CSF rhinorrhea and otorrhea and assess the clinical outcomes of patients presenting to a level 1 trauma center with posttraumatic CSF leaks who were managed by both surgical and nonsurgical means. PATIENTS AND METHODS: The records of all patients with basilar skull fractures and/or severe facial trauma presenting to a major level 1 trauma center from 1991 to 2001 were reviewed. Patients diagnosed with CSF otorrhea or rhinorrhea, who had not undergone an intracranial procedure, elevation of depressed skull fractures, or received a ventriculostomy, were identified and their demographics recorded. For purposes of statistical comparison, patients were divided into 2 groups: "leak" and "no leak." All patients in the leak group were initially observed for a period of 7 to 10 days. Persistent CSF leaks were managed by CSF diversion via lumber drainage for 5 to 7 days. Extracranial repair was performed only if lumbar drainage failed to resolve the leak. RESULTS: Seven hundred thirty-five patients were identified who met the criteria for inclusion in the study. Thirty-four patients (incidence, 4.6%) were identified with CSF leak presenting as otorrhea (n = 25 [75.8%]) or rhinorrhea (n = 9 [26.5%]), which was diagnosed by clinical, laboratory, or radiographic examination (average age, 28.2 years; age range, 2 to 80 years; 23 males and 11 females). All patients in this study experienced successful resolution of CSF otorrhea or rhinorrhea by using a variable combination of observation, CSF diversion, and extracranial repair. There were no complications or cases of meningitis. Twenty-eight patients (84.6%) experienced uncomplicated resolution of the leak without treatment in 2 to 10 days. Persistent CSF leak, defined by drainage greater than 7 days after injury, was identified in 6 patients (incidence, 0.8%), all except 1 who underwent CSF diversion via a lumbar drain for a period of 5 to 10 days. Two of these patients were treated successfully; the remaining 4 patients required surgical procedures. CONCLUSIONS: Post-traumatic CSF leaks are uncommon and will usually resolve without surgical intervention. Successful management in refractory cases often involves a combination of observation, CSF diversion, and/or extracranial and intracranial procedures.