introduction

The therapy of a skull base fracture depends above all on the extent of damage to surrounding structures due to the fracture. Not every scullbone fracture requires immediate surgery. However, there are some situations where immediate intervention is needed. Important to mention here is above all the open skull-brain trauma, which is usually caused by accidents. An involvement of cranial nerves is an absolute indication for surgery, for example, if the eye nerve (second cranial nerve) is affected by entrapment and threatens to blindness or even if the seventh cranial nerve is damaged, which is responsible for the facial muscles and in whose failure it comes to facial paralysis ( Facial nerve palsy ). Another situation in which urgency is needed is massive loss of nerve fluid ( cerebrospinal fluid ) and blood or even impalement of the head with a foreign body.

Conservative therapy

If there is no displacement of the ends of the fractures, then one can start a wait-and-see, conservative therapeutic attempt with regular control of bleeding and inflammation. If the above situations do not occur, this can often be enough. Even with tympanic membrane defects or accumulation of blood in the middle ear, healing is often achieved by waiting. If nerve water escapes from the ear ( otogenic liquorrhoea ), it is treated with an antibiotic to prevent the infiltration of bacteria and thus inflammation.

One then treats symptomatically eg with antivertiginosa for dizziness or pain medication. It is discussed whether a prophylactic administration of antibiotics for the prevention of dangerous meningitis ( meningitis ) or even encephalitis ( encephalitis ) makes sense. Opinions vary, and it certainly makes sense to discuss this issue with the attending physician in each individual case, depending on the severity of the injury.

surgery

On the other hand, it will be different if one of the above situations occurs, or if there is an escape of nerve water from the nose ( rhinogenic liquor reflux ). Here is an operation displayed. The surgical procedure is usually to pressure the tissue damaged by the trauma or fracture, thus preventing irreversible damage from relieving it. In addition, the fracture ends must be brought back into the correct anatomical position so that a healing and especially a stability of the bones can be ensured. Because unstable fractures or a growing together of the bones in the anatomically incorrect position can also secondary to pressure damage to nerves or vessels in the brain and / or facial skull area lead.

Partly, both injuries of the hard meninges ( dura mater ) have to be sewn again, as well as the bone defects are covered with filling material. For this purpose, one uses in the most optimal case the body's own tissue, such as so-called fascia (= connective tissue, for example, the muscle groups wrapped) or fibrin glue (= two-component adhesive, the tissue connects). For these substances, the risk of rejection of the body is much lower than for synthetically manufactured products.

If there are major defects, then metal plates or pins can be used, with which the fracture ends are stabilized again so that a convergence and thus the restoration of the necessary stability can take place. The use of these metallic parts is rather rare. If the skull has been crushed by the fracture, it will be raised again in the operation.

If it comes by a participation of vessels to a strong bleeding, the injured vessel must be closed again by means of a vascular suture. Often affected is the internal carotid artery ( internal carotid artery ), as it is endangered in its course at the skull base in fractures of the same. If it is necessary to open the skull to treat the fracture, this usually falls within the purview of the neurosurgeon.

However, in fractures of the facial skull and the oral and maxillofacial surgeon can be used. If the eyes are affected by injury to the second cranial nerve ( optic nerve ) or hearing by involvement of the eighth cranial nerve ( vestibulocochlear nerve ), the ophthalmologist or ENT specialist may also be involved in the treatment.

complications

With regard to the possible complications, especially the wound healing disorders due to infections or repeated irritations should be mentioned. In rare cases, if vessels are injured, rebleeding may occur, which then has to be stopped in a second treatment / operation. If cranial nerve involvement and concomitant neurological deficits occurred during craniofacial fracture, it is likely that recovery of the nerves will take a very long time. However, it can also lead to permanent nerve damage, if the decompression of the nerves has taken too long, or the damage to the nerve itself are just too big. The brain itself can of course be affected and it can lead to irreparable brain damage. These can range from mild symptoms such as concentration and memory disorders or personality changes to very serious damage. The worst complication is certainly the so-called apallic syndrome (wax coma), in which the entire function of the cerebrum is lost, whereas the function of the cerebellum, diencephalon, brainstem and spinal cord is preserved. Patients appear awake to the viewer but can no longer interact with their environment.

Therefore, one should take care of a rehabilitation option at an early stage in case of existing neurological deficits or persistent symptoms after skull base fracture. This significantly improves the patient's outcome. In the case of severe brain damage, admission to special clinics is also possible in which an attempt is made to restore the everyday fitness of the patient through intensive care and support.


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