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Fracture of base of skull — Clinical Guidelines

Overview

Fractures of the base of the skull involve the bony structures surrounding the brain, often resulting from trauma and potentially leading to neurological deficits, cerebrospinal fluid leaks, and vascular complications. 18 24

Diagnosis

Clinical Presentation: Headache, cranial nerve palsies, visual disturbances, and signs of increased intracranial pressure.

Imaging: CT scan is the primary imaging modality; MRI may be necessary for detailed soft tissue assessment.

Special Imaging Considerations: Routine head CT can depict skull base lesions but requires careful interpretation to avoid overlooking subtle findings 7.

Diagnostic Challenges: Recognition of skull base elements in imaging can vary among practitioners, necessitating specialized training 6.

Management

Surgical Intervention: Endoscopic endonasal approaches are increasingly favored for anterior skull base fractures and associated lesions 1 11 18.

Antibiotic Prophylaxis: Prophylactic antibiotics are used in endoscopic endonasal skull base surgeries to reduce infection risk, though regimens vary 2.

Reconstruction: Extensive resection and flap reconstruction are crucial for lateral skull base defects to ensure functional and aesthetic outcomes 5.

Postoperative Care: Includes nasal hygiene, gradual mobilization, and careful monitoring for complications like CSF leaks 1.

Radiation Therapy: Target volume delineation guided by multidisciplinary guidelines ensures precise treatment of skull base tumors 3.

Neurological Monitoring: Continuous monitoring for neurological deficits and intracranial pressure management post-fracture 18.

Special Populations

Pregnancy: Management requires careful consideration of fetal well-being alongside maternal health, often necessitating multidisciplinary consultation 9.

Elderly: Increased risk of comorbidities necessitates tailored surgical approaches and postoperative care plans 1 18.

Key Recommendations

Utilize CT scans for initial diagnosis of skull base fractures, with MRI reserved for detailed soft tissue evaluation 7. (Evidence: Moderate)

Implement endoscopic endonasal approaches for anterior skull base fractures when feasible, emphasizing multidisciplinary collaboration 1 18. (Evidence: Moderate)

Employ prophylactic antibiotics in endoscopic endonasal skull base surgeries to mitigate infection risk, though standardized regimens are lacking 2. (Evidence: Weak)

Ensure meticulous postoperative care, including nasal hygiene and gradual patient mobilization, to prevent complications 1. (Evidence: Expert opinion)

Tailor surgical and medical management in elderly patients considering their higher comorbidity rates 18. (Evidence: Expert opinion)

References

1 Douglas JE, Adappa ND, Choby G, Levine CG, Rabinowitz MR, Sindwani R et al.. American Rhinologic Society expert practice statement part 2: Postoperative precautions and management principles following endoscopic skull base surgery. International forum of allergy & rhinology 2024. link 2 Kwon TH, Shin HK, Yoon WK, Kim JH, Byun J. Antibiotics Prophylaxis for Endoscopic Endonasal Approach for Skull Base Tumor Surgery: A Meta-Analysis. World neurosurgery 2023. link 3 Combs SE, Baumert BG, Bendszus M, Bozzao A, Brada M, Fariselli L et al.. ESTRO ACROP guideline for target volume delineation of skull base tumors. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology 2021. link 4 Silver JA, Mascarella M, Tali G, Varshney R, Tewfik MA, Tajudeen BA et al.. Levels of Evidence in Rhinology and Skull Base Surgery Research. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2021. link 5 Vozel D, Pukl P, Groselj A, Anicin A, Strojan P, Battelino S. The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience. Radiology and oncology 2021. link 6 Mohammadzadeh M, Abdullah H, Davoodian A, Akbari A, Erfanian R. Assessing the abilities of senior otolaryngology residents and graduated otolaryngologists in recognizing skull base elements in axial CT scan: proposing a new method for differentiating superior orbital fissure and optic canal. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2021. link 7 Bello HR, Graves JA, Rohatgi S, Vakil M, McCarty J, Van Hemert RL et al.. Skull Base-related Lesions at Routine Head CT from the Emergency Department: Pearls, Pitfalls, and Lessons Learned. Radiographics : a review publication of the Radiological Society of North America, Inc 2019. link 8 Phan J, Pollard C, Brown PD, Guha-Thakurta N, Garden AS, Rosenthal DI et al.. Stereotactic radiosurgery for trigeminal pain secondary to recurrent malignant skull base tumors. Journal of neurosurgery 2019. link 9 Priddy BH, Otto BA, Carrau RL, Prevedello DM. Management of Skull Base Tumors in the Obstetric Population: A Case Series. World neurosurgery 2018. link 10 AlQahtani AA, Albathi AA, Alhammad OM, Alrabie AS. Innovative real CSF leak simulation model for rhinology training: human cadaveric design. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2018. link 11 Horowitz PM, DiNapoli V, Su SY, Raza SM. Complication Avoidance in Endoscopic Skull Base Surgery. Otolaryngologic clinics of North America 2016. link 12 von Sass PF, Scheckenbach K, Wagenmann M, Klenzner T, Schipper J, Chaker A. Taking a fresh look at the skull base in otorhinolaryngology with web-based simulation: Student's Interactive Skull-Base Trainer (SISTer). JAMA otolaryngology-- head & neck surgery 2015. link 13 Felisati G, Pipolo C, Maccari A, Cardia A, Revay M, Lasio GB. Transnasal 3D endoscopic skull base surgery: questionnaire-based analysis of the learning curve in 52 procedures. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2013. link 14 Batra PS, Lee J, Barnett SL, Senior BA, Setzen M, Kraus DH. Endoscopic skull base surgery practice patterns: survey of the North American Skull Base Society. International forum of allergy & rhinology 2013. link 15 Samara L, Alobid I, Enseñat J, De Notaris M, Bernal-Sprekelsen M. Neurosurgeon-otolaryngologist collaboration in endonasal approaches to the clivus and suprasellar region. B-ENT 2011. link 16 Nogueira JF, Stamm A, Vellutini E. Evolution of endoscopic skull base surgery, current concepts, and future perspectives. Otolaryngologic clinics of North America 2010. link 17 Cousins VC. Lateral skull base surgery: a complicated pursuit?. The Journal of laryngology and otology 2008. link 18 Russell PT, Weaver KD. Anterior endoscopic skull-base surgery getting started: an otolaryngologist's perspective. Current opinion in otolaryngology & head and neck surgery 2007. link 19 Lustig LR. Anesthesia, antisepsis, microscope: the confluence of neurotology. Otolaryngologic clinics of North America 2007. link 20 Cavel O, Fliss DM, Segev Y, Zik D, Khafif A, Landsberg R. The role of the otorhinolaryngologist in the management of central skull base osteomyelitis. American journal of rhinology 2007. link 21 Caversaccio M, Langlotz F, Nolte LP, Häusler R. Impact of a self-developed planning and self-constructed navigation system on skull base surgery: 10 years experience. Acta oto-laryngologica 2007. link 22 Jung TM, TerKonda RP, Haines SJ, Strome S, Marentette LJ. Outcome analysis of the transglabellar/subcranial approach for lesions of the anterior cranial fossa: a comparison with the classic craniotomy approach. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 1997. link 23 Carney AS, Patel N, Baldwin DL, Coakham HB, Sandeman DR. Intra-operative image guidance in otolaryngology--the use of the ISG viewing wand. The Journal of laryngology and otology 1996. link 24 Feghali JG. Skull base surgery: an emerging new specialty. Le Journal medical libanais. The Lebanese medical journal 1994. link 25 Janecka IP. Surgical approaches to the skull base. Neuroimaging clinics of North America 1994. link 26 Zanella FE, Valavanis A. Interventional neuroradiology of lesions of the skull base. Neuroimaging clinics of North America 1994. link

Fracture of base of skull