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Skull base and maxillofacial fractures: Two centre study with correlation of
clinical findings with a comprehensive craniofacial classification system
CHLI1, Christoph LEIGGENER2,7, Petter GAWELIN3, Laurent AUDIGE4, Per ENBLAD5,
Heidi BA
Hans-Florian ZEILHOFER2,7, Jan HIRSCH3, Carlos BUITRAGO-TELLEZ6,7
1
Department of Neurosurgery, University Hospital Basel, Switzerland; 2 Department of Reconstructive Surgery, Unit
of Cranio-Maxillofacial Surgery, University Hospital Basel (Head: Prof. Dr. F. Zeilhofer), Switzerland; 3 Departments of
Surgical Sciences, Oral and Maxillofacial Surgery, Uppsala University Hospital, (Head: Prof. Dr. J. Hirsch), Sweden;
4
AO Clinical Investigation and Documentation, Dubendorf (AO Foundation), Switzerland; 5 Departments of Surgical
Sciences, Neurosurgery, Uppsala University Hospital, Sweden; 6 Institute of Radiology, Hospital Zofingen (Head:
Radiology Hospital Zofingen), Switzerland; 7 Hightech Research Centre for Cranio-Maxillofacial Surgery, University
Hospital Basle (Head: Prof. Dr. F. Zeilhofer), Switzerland
Keywords: skull base fractures, cranio-maxillofacial injury severity score (CMF-ISS), periorbital haematoma,
pneumencephalus, rhinorrhoea
INTRODUCTION
Skull base fractures are a great challenge for the surgeons
involved. The treatment is still controversial including best
operative approach, urgency and extent of surgical procedure. The singular anatomical relationship of the skull base
is the reason for particular problems that may arise after injury such as dural laceration, severe neurovascular damage
e.g. (Samii and Tatagiba, 2002). The decision on management must consider all these aspects. Another important
point is that a lot of patients are polytraumatized including
severe brain injuries which complicates early operative interventions. Additionally the involvement of different specialities, such as oral and maxillofacial surgeons,
neurosurgeons, plastic surgeons and ENT may lead to controversies about therapeutic decisions, including timing reconstruction and specific kind of technical procedures
(Kessler and Hardt, 1998; Samii and Tatgiba, 2002; Gabrielli et al., 2004; Sandner et al., 2006).
It is well known that there is a high coincidence of
fractures and dural lacerations. But the problem is that
there is not always sufficient information about the real
1
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
2 Journal of Cranio-Maxillofacial Surgery
a comprehensive classification system with different severity scores (Buitrago-Tellez et al., 2002). To tackle
this problem, the present study is based on a retrospective
evaluation of patients with skull base and maxillofacial
fractures in two clinical centres.
MATERIAL AND METHODS
Patients
A retrospective analysis (1997e2005) of the clinical data
of a total of 70 patients (55 males, 15 females) with craniofacial fractures which were managed by neurosurgery
and maxillofacial surgery of the University Hospital of
Basel (Switzerland; n 29) and Uppsala (Sweden;
n 41). The patients were aged between 5 and 80 years
(mean 43.4).
Radiology
CT-studies of the craniofacial region performed in the
acute setting were available for classification. CT-Studies
were obtained either in single or multislice-CT technique
with collimation of 1.5 mm with secondary 2D coronal
reconstructions with a SOMATOM PLUS S scanner,
Volume Zoom (Siemens, Erlangen, Germany) or GE
CT (GE, Milwaukee, USA) scanner. 3D CT reconstructions were obtained in selected cases. Clinical signs (rhinorrhoea, periorbital haematoma and pneumencephalus)
were registered in the clinical records.
Fracture Classification System
For the purpose of this study, all cases were classified
according the comprehensive classification of craniofacial fractures proposed by the senior author (BuitragoTellez et al., 2002). Fig. 1 shows a cranio-midfacial
view with skull base (red) and calvarial (green) compo-
Fig. 1 e Cranio-midfacial views with division lines for the skull base (red) and calvarial (green) components of the craniobasal-calvarial unit of the
craniomidface. (a) Front view showing the calvarial (green) and skull base (red) components of the craniobasal-calavarial unit. The skull base
component includes in this view the laterobasal aspect of the sphenoid bone (greater wing) until the level of the dorsal lateral orbital wall and the orbital
roof. The calvarial component includes the parietal, frontal and squamoustemporal calvarial bones, the supraorbital rim and the anterior wall of the
frontal sinus. (b) Top view showing the calvarial (green) and skull base (red) components of the craniobasal-calavarial unit. The skull base component
includes in this view the FB and laterobasal aspect of the sphenoid bone, the dorsal wall of the frontal sinus, the orbital roof, the rhinobasis with the
cribriform plate, the middle fossa, the clivus, the petrous part of the temporal bone and the dorsal occipital skull base. The calvarial component includes
the parietal, F and squamoustemporal bones and the anterior wall of the frontal sinus.
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
Skull base and maxillofacial fractures 3
Fig. 2 e Buitrago-Craniofacial Fracture Automatic Classifier (CAFFAC) 2004. Note that A-fractures (non-displaced) appear green; B-fractures
(displaced) orange and C-fractures (multifragmentary) red.
RESULTS
CT evaluation was performed in consensus by two experienced readers (radiologist and neurosurgeon in Basel,
radiologist and maxillofacial surgeon in Uppsala). For
classification purposes, the CAFFAC software was
used drawing the fracture lines on the craniofacial
scheme. The software automatically gives the fracture
formula in all four compartments. Furthermore, the software calculates a Cranio-Maxillofacial Injury Severity
Score (CMF-ISS) which results from the sum of the
scores in all compartments with a weighting system emphasising the presence of skull base fractures. The fracture types (A, B or C) are multiplied by a factor 2, the
group by a factor 3 and the subgroup by a factor 1.
This calculation is made for each compartment (max.
value for one compartment 18 points).
For example, a complete multifragmentary fracture of
the craniofacial region with all compartments involved
would get a maximum of 72 points (4 18 points).
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
4 Journal of Cranio-Maxillofacial Surgery
Fig. 3 e Cranio-midfacial fracture with FB component. Involvement of all four vertical compartments: (right lateral/right central left central/left
lateral), involving midface and fronotobasis (arrows). Fracture formula: C3.2/C3.2//C3.2/C3.2.
Another problem is the complex anatomy of the FB region which leads to the development of several classification systems with different nomenclature (Kienstra and
VanLoveren, 2005). Detailed definition of specific regions were described, such as nasoethmoidal fractures
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
Skull base and maxillofacial fractures 5
(Gruss, 1985; Markowitz et al., 1991), nasoethmoid-orbital injuries (Fedok, 1995), orbito-zygmatic fractures
(Zingg et al., 1992), frontonaso-orbital/skull base fractures and telecanthus (Raveh et al., 1992) or malar complex fractures (Fujii and Yamashiro, 1983). Frontal sinus
fractures are also frequently involved in skull base fractures including their own classification schemes (Rohrich
and Hollier, 1992; Manolidis, 2004) and surgical management. Missing in all these classifications is the midfacial region which is often consecutively involved because
of the high velocity impact of accidents. Mahusudan
et al. (2006) proposed a new comprehensive clinicoradiographic classification which defines anatomical areas
within the FB region, the nature of an injury associated
with midfacial injuries. He divided nine types which include the whole anteroposterior and lateral FB region. He
differentiates three main types: central (type 1), lateral
(type 2) and combined (type 3). Subregions were divided
into frontal (F) including cranial vault, basal (B) with the
floor of the anterior cranial fossa, ethmoid and lateral orbital walls and FB with both frontal and basal regions.
The fracture was called impure if there was a midfacial
fracture and pure without. 48.7% of patients with impure
FB fractures showed cerebrospinal fluid leaks, only
16.7% with pure fractures. This must be noted with
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
6 Journal of Cranio-Maxillofacial Surgery
due to different speed limits and different legal blood alcohol limits.
Another interesting point is that in Uppsala, patients
with an ISS between 40 and 60, who would be treated
operatively in Basel, received conservative therapy.
One reason for this may be the more aggressive treatment
of skull base fractures in Basel. CSF rhinorrhoea especially with fractures of frontal sinuses was an indication
for surgical approach in Basel.
Treatment of CSF rhinorrhoea in skull base fractures is
still a controversial topic in the literature. Most CSF leaks
close spontaneously, especially in cases of temporal bone
fractures rather than in anterior fossa fractures (Yilmazlar
et al., 2006). On the other hand, subdural empyema or
brain abscesses developing months or years after trauma
are consequences of untreated CSF leaks. The literature
described 10e50% trauma induced meningitis in patients with CSF fistulas (Yilmazlar et al., 2006). Rocchi
et al. (Rocchi et al., 2005) also identified in a series of
36 patients also a relatively high risk of meningitis associated with dural fistulas, even in those patients who were
treated conservatively. The treatment of persisting fistulae is undisputed because of subsequently high infection
rate. Some neurosurgeons therefore stipulate that all CSF
fistulae should be treated operatively as soon as possible
(Cairns, 1937; Loew et al., 1984). Yilmazlar et al. (Yilmazlar et al., 2006) correlated treatment options with
the severity of neurological deficits and the presence of
intracranial lesions at admission. He offers a treatment algorithm in which patients with associated cranial lesions
were operated upon and those without got CSF drainage.
In this study, the evaluation of correlation of the CMFISS patients with rhinorrhoea revealed a significant association (univariable analysis) with the score system.
However, when adjusting for age, gender and treatment,
the association was no longer significant. This may be
explained by the fact that isolated or less extensive or
non-displaced fractures of the frontal skull base with rhinorrhoea may have a low score and depending of the
therapeutic approach or other factors be operated upon.
Pretto Flores and colleagues (Pretto Flores et al.,
2000) showed that selected clinical signs such as Battles
sign and unilateral blepharohaematoma had higher predictive values for skull base fractures and intracranial lesions even in patients with Glasgow Coma Scale (GCS)
between 13 and 15 which indicates the need for further
radiological investigations. The association of raccoon
eyes with skull base fractures has been described by
several authors too (Goh et al., 1997; Kral et al., 1997;
Herbella et al., 2001).
In our study patients with or without periorbital haematoma showed no difference in severity score. This
means that the presence of such a haematoma does not
allow a definitive conclusion about the severity and extent. Clinical signs of skull base fractures such as periorbital haematoma, rhinorrhoea or pneumencephalus are
not strong enough to justify a decision to perform surgical repair. However, according to the results, a CMF-ISS
score of over 60 points was clearly correlated with an operative approach in both centres.
The exact mechanisms which lead to combined facial
and cranial fractures are still unclear but high energy
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008
ARTICLE IN PRESS
Skull base and maxillofacial fractures 7
Kessler P, Hardt N: Results of transcranial and subcranial management
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CHLI
Dr. Heidi BA
Department of Neurosurgery, University Hospital Basel, Spitalstrasse
21, CH-4031 Basel, Switzerland
Tel.: +41 61 265 7522; Fax: +41 61 265 7138
E-mail: hbaechli@uhbs.ch
Paper received 27 March 2008
Accepted 22 January 2009
Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008