EMReports | Pearls and Pitfalls - Frontal Sinus Fractures and CSF Leak

Frontal Sinus Fractures and CSF Leak

Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia
and
Eric Greenfield, DO
Department of Emergency Medicine
Medical College of Georgia

Pearl: Consider the possibility of cerebrospinal fluid leak in patients with frontal sinus fractures.

Presentation: On the afternoon of presentation, a 21–year–old male college student was playing a pickup game of football with his friends. None of the participants wore protective gear. While tackling another player, the patient's forehead struck an opponent's knee. At the time of the injury, other players and observers described an audible cracking sound. Following the impact, the patient did not lose consciousness, experienced immediate frontal head pain, and a visible depression was noted on his forehead.

On arrival in the emergency department, the patient was alert and oriented and described a severe headache. He denied neck pain. His initial vitals were: temperature 36.7 Celsius; pulse 77; RR 20; SaO2 100% on room air; BP 145/78. His neurologic examination demonstrated no focal findings. His forehead demonstrated a visible depression. (See Figure 1.) A CT scan of the head and a cervical spine series were obtained. The CT scan demonstrated a depressed skull fracture involving the nasofrontal suture to the right of midline and the anterior wall of the right frontal sinus above the right medial canthal margin. There was also a smaller fracture component involving the posterior wall of the right frontal sinus at the frontal recess, with extension into the orbital plate of the right frontal bone, with secondary right orbital emphysema. There was also a minimal punctate amount of pneumocephalus adjacent to the intracranial fracture. (See Figure 2.) The patient's headache was improved after paraspinous injection with bupivacaine 0.5%. Neurosurgery and plastic surgery were consulted. Initially the patient denied nasal drainage consistent with a cerebrospinal fluid (CSF) leak, but subsequently reported an intermittent flow of clear fluid from his nose.

The next day, the patient went to the operating room and the plastic surgery service elevated the frontal sinus bone, explored and confirmed minor cracks on the posterior aspect of the sinus, instrumented the frontonasal duct, reduced the nasal bone fracture, and replaced the pieces of bone with a titanium plate and screws. The patient tolerated the repair without complications and was discharged home. At follow–up, the patient was doing well with no complications from the procedure.

Discussion: Fractures of the frontal sinus can be associated with life–threatening intracranial complications such as meningitis or the development of a brain abscess. Other reported complications include frontal osteomyelitis, non–union of the frontal bone, cavernous sinus thrombosis, mucopyocele, meningoencephalocele, and CSF leak.

Blunt trauma is the most common cause of CSF fluid leak and should be highly suspected in frontal sinus fractures. If available, the definitive test for identifying CSF in rhinorrhea is the β2–transferrin test.¹ Testing for nasal fluid glucose has a low specificity but a fairly high negative predictive value. After head trauma the incidence of posttraumatic meningitis ranges from 0.2% to 17.8% and occurs most frequently in the presence of skull base fracture, pneumocephalus, or CSF.^2,3 Patients should be informed to avoid nose blowing, sneezing, or coughing. Otolarygology and neurosurgery should be consulted. Antibiotic prophylaxis is controversial, but can be considered.4 Potential choices include ceftriaxone and metronidazole.⁵ A Cochrane review states that, "currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed."⁶

References:

Warnecke A, Averbeck T, Wurster U, et al. Diagnostic relevance of beta–2 transferrin for the detection of cerebrospinal fluid fistulas. Arch Otolarygol Head and Neck Surg 2004;130:1178–1194.
Kaufman BA, Tunkel AR, Pryor JC, et al. Meningitis in the neurosurgical patient. Infect Dis Clin North Am 1990;4:677–701.
Helling TS, Evans LL, Fowler DL, et al. Infectious complications in patients with severe head injury. J Trauma 1988;28:1575–1577.
Villalobos T, Arango C, Kubilis P, et al. Antibiotic prophylaxis after basilar skull fractures: A meta–analysis. Clin Infect Dis 1998;27:364–369.
Eftekhar B, Ghodsi M, Nejat F, et al. Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus:results of a clinical trial. J Neurosurg 2004;101:757–761.
Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

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