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6 Diagnosing Injuries of the Skull Base

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6 Diagnosing Injuries of the Skull Base 6 Diagnosing Injuries of the Skull Base Flowchart Injuries of the Skull Base, Chapter 3, Treatment of Injuries of the Skull Base, Chapter 17, p. 17. p. 140. Surgical Anatomy n The bony architecture of the skull base can be divided into Q ethmoid bone; three depressions: the anterior, middle, and posterior crani- Q frontal bone; al fossae. Q sphenoid bone; Q temporal bone; The interior surface of the cranial base is comprised of Q occipital bone. the following (Fig. 6.1): Fig. 6.1 Overview of the anatomic structures of the skull base (from Tillmann 1997). 45 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG 6 Diagnosing Injuries of the Skull Base Anterior Cranial Fossa The middle cranial fossa is also partially formed by the temporal bone, which is made up of petrous (pyra- The anterior cranial fossa is made up of two bones: the mid), squamous, and tympanic portions. The roof of the ethmoid bone and the frontal bone. These form the floor, tympanic cavity (tegmen tympani) and antrum (tegmen sides, and anterior wall of the cranial base. The boundary antri) thus forms part of the floor of the middle cranial to the middle cranial fossa is formed by the lesser wings fossa. of the sphenoid bone. The anterior skull base provides The optic canal, containing the optic nerve and oph- the roof for the pair of orbital cavities and the upper por- thalmic artery, is located in the middle cranial fossa. Lat- tion of the nasal cavity. eral to the apex of the petrous pyramid is the trigeminal At the center of the anterior cranial fossa is the cribri- ganglion of the trigeminal nerve. The trigeminal ganglion form plate, part of the ethmoid bone. Traversing the cri- emerges as the mandibular nerve from the foramen briform plate through openings in the plate are the fine ovale and as the maxillary nerve from the foramen ro- olfactory nerves, which are covered by a dural sheath tundum. The foramen spinosum transmits the middle and enclosed in the subarachnoid space. There can be meningeal arteries. The foramen lacerum, transmitting considerable differences in height between the ethmoid the greater superficial petrosal nerve, is located in front bone and the cribriform plate. In the center of the cribri- of the carotid canal in which the carotid artery lies. form plate is a sagittally positioned bony process, the After entering the cranial cavity, the internal carotid crista galli, which is sometimes pneumatized. The cere- artery travels in the carotid canal lateral to the cavernous bral falx, which divides the two halves of the brain, is sinus for a short distance. firmly anchored to the crista galli. Posterior Cranial Fossa Middle Cranial Fossa The posterior cranial fossa is separated from the middle The middle cranial fossa is divided by the pituitary fossa cranial fossa by the edge of the petrous pyramid. At the (sella turcica), which contains the pituitary gland at its center of the pyramid is the opening to the internal center. On the posterior side of the pituitary fossa, the acoustic meatus, which transmits the vestibulocochlear clivus slopes down toward the posterior cranial fossa. nerve, facial nerve, and labyrinthine vessels. Diagnostic The pituitary fossa is formed by the sphenoid body with Directly adjacent to the pyramid is the sigmoid sinus, the lesser and greater wings of sphenoid bone: which flows into the jugular bulb and exits the cranial Q The greater wings of the sphenoid bone (ala major) are fossa together with the glossopharyngeal nerve, vagus two bony plates that descend from either side of the nerve, and accessory nerve—via the jugular foramen. The pituitary fossa to create part of the floor of the middle foramen magnum is the largest opening in the posterior cranial fossa. cranial fossa, allowing entrance of the medulla oblongata Q The lesser wings of the sphenoid bone (ala minor) trav- and vertebral artery into the cranial cavity. el horizontally toward the lateral cranial fossa. Enclosing the brain is the dura mater, which is made up of an inner and outer layer. The outer layer forms the Between the lesser and greater wings of the sphenoid periosteal covering of the cranial bone. This internal peri- bone is a gap, the superior orbital fissure, containing the osteum is firmly attached near the crista galli. At the pos- trochlear nerve, abducens nerve, oculomotor nerve, oph- terior wall of the frontal sinuses, the periosteum gradu- thalmic nerve, and superior orbital vein. ally separates from the bone. Pathomechanism and Classification Injuries of the skull base can be divided into bursting Bursting fractures are caused by objects with a wide fractures and bending fractures. surface area and indirect trauma to the cranial bones. The resulting force is transmitted and, in areas where the bone is thin, minimal elasticity results in breakage, i. e., Pathomechanism bursting fractures (Fig. 6.2b). Bending fractures are caused by direct, focused trauma to the skull. Depression of the bone at the site of impact results, which typically produces comminuted or perfo- rated fractures (Fig. 6.2a). 46 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG Pathomechanism and Classification Fig. 6.2 Etiology of bending (a) and bursting fractures (b). a Focused trauma leads to primary fissure formation on the opposite surface of the bone, or to com- plete fracture, given sufficient a force. b Impact over a broad area of bone leads to compression, and ulti- mately a bursting fracture of the skull base. b Dural Injury Classification of Fractures Osseous injury of the skull base can cause a tear in the Injuries of the anterior skull base are classified in various dura mater, attached to the bone. ways. Classification by the anatomic region involved (Fig. 6.3) can be made as shown in Table 6.1. n The firm attachment in the nasal fossa region of the dura mater makes this a site at high risk of injury. Table 6.1 Classification of anterior skull base fractures The dura mater is a bradytrophic tissue; healing is slow and occurs with connective tissue scar formation. In in- Region I Posterior wall of frontal sinuses juries involving the skull base, resulting swelling of the brain can cause a defect in the cranial base without pri- Region II Anterior cribriform plate of the ethmoid bone mary cerebrospinal fluid leak. Region III Posterior ethmoid The arachnoid membrane closes much more quickly than the dura mater, so that cerebrospinal fluid leakage Region IV Sphenoid sinus can no longer be detected. Wound closure with arach- Region V Orbital roof noid tissue, however, does not offer sufficient protection against infection arising from the paranasal sinuses. 47 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG 6 Diagnosing Injuries of the Skull Base Fig. 6.3 Anterior skull base. 1 2 3 4 a Anatomy on a view of the para- 5 nasal sinuses. 1 Frontal sinus. a 2 Posterior wall of the frontal 6 sinus. 3 Crista galli. 4 Cribriform plate. 5 Anterior/middle ethmoid 7 bone. 6 Posterior ethmoid bone. 8 7 Sphenoid sinus. 8 Lesser wing. 9 9 Pituitary fossa. 10 Middle cranial fossa (greater wing of sphenoid). 10 11 Superior orbital fissure. 11 12 Foramen rotundum. 13 Fora- men ovale. 12 b Classification of anterior skull base fractures based on anatomic region (for regions I–V see Table 13 6.1, p. 47). b I I V II Diagnostic III IV Clinical Signs and Symptoms Table 6.2 Clinical signs of an anterior skull base injury Symptoms of injury to the cranial base can be divided Uncertain signs Certain signs into clinically certain and uncertain signs (Table 6. ). 2 Eyelid hematoma, Cerebrospinal rhinorrhea eyelid emphysema Uncertain Signs of Fracture of the Epistaxis Pneumocephalus Anterior Skull Base Seiferth sign Early meningitis Eyelid Hematoma, Eyelid Emphysema Olfactory disturbance Extruding brain matter Eyelid hematomas can arise from craniofacial injury or from injury of the orbital roof. There is unilateral or bilat- eral swelling of the upper lids and also blue discoloration Vision must be tested for any injury involving the re- in early stages. Swelling can obstruct or impair opening ! gion around the eye and eyelid. Instruments (eyelid of the eyelid. hooks, etc.) should be used if necessary for opening the lids. 48 Ernst/Herzog/Seidl, Head and Neck Trauma (ISBN 3131400013, 9783131400017), 2006 Georg Thieme Verlag KG Clinical Signs and Symptoms The eyelids are separated by a partition, the orbital sep- Olfactory Disturbances tum, allowing localization of injuries in the orbital re- gion. Evaluation is made with eversion of the upper lid Olfactory disturbances may be caused by direct injury (see Fig. 6.4a). (avulsion of olfactory nerve fibers from the cribriform Q Craniofacial injuries result in visible hematomas ven- plate) or indirect injury (hyperextension of the olfactory tral to the orbital septum only, which can be seen with- nerve fibers in shearing movements of the brain) of the in a short time following trauma (Fig. 6.4b). olfactory nerve fibers. Various methods can be used to Q Injuries of the skull base exhibit lid hematomas dorsal test olfactory ability. and ventral to the orbital septum. Because of the longer Odorants have a detection threshold and a recognition distance to the lid, these hematomas may be observed threshold. Testing substances can be divided into: some time after injury occurred (Fig. 6.4c). Q pure odorants that only stimulate the olfactory nerve (coffee, vanilla, cinnamon, gasoline); If air enters the lid apparatus from the nose and para- Q odorants that also stimulate the trigeminal nerve nasal sinuses (e.
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