facial trauma and csf leak.pptxby dr junaid iqbal

Facial trauma

1. FACIAL TRAUMA & CSF LEAK By Dr Junaid Iqbal ENT Resident CMH KHN

2. Initial Approach ABC Stabilize patient & Rule out Life or Limb threatening injuries Establish Airway Ensure adequate ventilation Control Bleeding

3. AIRWAY MANAGEMENT Major facial trauma assc . With risk of uppr airway obstruction Protect C Supine (5-10%)

4. MASSIVE HEAMORRHAGE Life threating bleeding occurs in 1.2-5% of all LeFort Fractures. Hemorrhage is generally controlled by direct pressure Brisk epistaxis may respond to Ant and Post Nasal packing

5. STANDARD CLINICAL ASSESMENT History Mode of injury, loss of consciousness, symptoms at examination, medications, alcohol or drugs and fasting status. General Examination External Examination for Hard / Soft injury. Inspection looking for oedema, ecchymosis and lacerations. Palpate for bony deformity. Orbital rims, zygomatic arches, nasal bones, mandibular body and condyles.

6. Neurologic Examination Cranial Nerve  V and VII  Intra-oral Examination Intra-oral examination in good lighting Inspect for ecchymosis in buccal or lingual sulci. Mucosal haematoma over underlying fractures Dentition and Occlusion New deformity indicates discrepant maxillary and/or mandibular position

7. Orbital Examination Ocular movements  ocular position. Intra- ocular pathology Close observation essential in zygoma fractures. Nasal Examination Septal haematoma, deviation, patency, CSF Rhinorrhoea Ear Examination Blood in EA canal, behind membrane, mastoid 

8. Bony Injuries Common Presentation – Nasal – Orbital Floor – Zygoma .Zygomatic Arch – Infra-orbital rim – Mandibular Less common – Frontal sinus – Nasoorbitoethmoidal NOE – Le Forte Fracture Patterns

9. CLASSIFICATION OF FACIAL FRACTURES Upper ⅓ 2. Middle ⅓ 3. Lower ⅓ Frontal Bone Maxilla Mandible Mandible Nasal Naso -ethmoids Orbitozygomatic “Pure” blowout 4. Panfacial Craniofacial Upper, middle, lower thirds

10. ZYGOMATIC ARCH

11. Orbital Floor Tethering vs entrapment • Diplopia, enopthalmos

12. Local Anaesthetics in   the Face • Infra-orbital nerve • Supra-orbital nerve • Mental nerve • Dorsal nasal nerves

13. CSF RHINORRHEA Leakage of CSF in to the nose • Clear • mixed with blood (in a/c head injuries)

14. Etiology Trauma (commonest) Accidental Surgical ( FESS, nasal polypectomy , trans sphenoidal hypophysectomy,skull base surgery) • Neoplasms (benign/malignant) invading skull base • Inflammations ( mucocele of sinuses , sinu nasal polyposis, fungal infections of sinusitis & osteomyelitis erode the bone & dura ) • Congenital ( meningocele,meningoencephalocele & glioma with skull base defect) • Idiopathic

15. Site of leakage   1. anterior cranial fossa a) Cribriform plate b) Roof of ethmoid c) Frontal sinus 2. Middle cranial fossa a)injuries to sphenoid sinus b) . In # of temporal bone CSF > ME > ET> nose (CSF otorhinorhea

16. Diagnosis • h/o  clear watery discharge on bending head/ straining • sudden gush can’t be sniffed back • Reservoir sign : When rising in morning csf collected in sinuses on bending head

17. After a  head trauma • Double target sign when collected on a piece of filter paper with central blood & peripheral llighter halo Nasal Endoscopy  localize site of CSF leak • Otoscopic /microscopic examination of ear } CSF otorrhinorhea

18. Laboratory tests  B2 transferrin • Sensitive & specific • Only few drops of csf is needed • Perilymph & aqueous also contains it but not in nasal discharge • Beta trace protein • Specific for CSF • Glucose testing • > 30 mg/dl in csf • <10 mg/dl in nasal discharge

19. Localisation of site  • High resolution CT scan • Coronal & axial cuts at 1-2 mm } bony defects • Axial } frontal & sphenoid sinus • MRI • T2 weighted image Site of leak • Active CSF leak is needed • Non invasive

20. Treatment Conservative  • Bed rest • Elevating the head • Stool softeners • Avoidance of node blowing, sneezing & straining • Prophylatic abx } meningitis • Acetazolamide } ↓ formn of CSF

21. Surgical repair •  Neurosurgical intra cranial approach • Extra dural approach • External ethmoidectomy } cribriform plate • Trans septal sphenoidal approach } sphenoid • Osteoplastic flap } frontal

22. Trans nasal  endoscopic approach • With endoscope • Site of leak 1. Cribriform plate 2. Lateral lamina close to anterior ethmoid a 3. Roof of ethmoid 4. Frontal sinus leak 5. Sphenoid sinus • Preparation of graft site • Underlay placement of graft extra durally (mucosa for small defect….. Septal cartilage if>2cm) • Surgical & gelfoam strengthen • Lumbar drain if CSF pressure is high • abx

23. Intrathecal fluorescein  study • Pre operatively }to dx site • Intra operatively for repair • Invasive • 0.25-0.5 ml of 5% fluorescein mixed with patients own CSF is injected & pt lies in 10 ’ head down position for some time dye ca be detected intranasally with the help of endoscope……….appears bright yellow but when seen with blue filter } flurescent green • Localise the lesion • CT cisternogram • Localise the lesion • Intrathecal injection of iohexol & CT • Where B2 transferrin can’t be done