Anterior Subcranial Approach - Trauma Workup

Updated: Dec 20, 2016
  • Author: Robert M Kellman, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

Lab studies may be an issue if assessing the presence of a CSF leak. Suggestive rhinorrhea fluid can be sent for a beta2-transferrin test to see if it is indeed CSF.

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Imaging Studies

When assessing central facial trauma, high-resolution CT scanning is key to the proper assessment of the extent of the fractures.

  • Whenever possible, obtain both axial and coronal scans; however, if only axial scans are possible (eg, if an associated cervical spine injury is present, if 3-dimensional reconstructions are desired), then 1.5-mm cuts should be used to maximize the quality of the coronal reconstruction.
  • Careful assessment of the orbits, optic canals, ethmoid roofs, cribriform plate, and posterior walls of the frontal sinuses helps determine the surgical plan.

If an osteoplastic bone flap is being considered, obtain and copy a 6-foot anteroposterior Caldwell view. A cutout of the frontal sinus is made from the copy and used to create the osteoplastic flap. As an alternative, image guidance may assist with defining the outlines of the frontal sinuses.

When evaluating a patient for possible CSF rhinorrhea from a previously managed trauma, the site of the leak may not be obvious. Generally speaking, finding the bony defect with high-resolution CT scanning is the most dependable way of identifying the site of a probable leak. However, if this is not possible, a metrizamide CT scan may occasionally reveal the site of a CSF leak.

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Other Tests

Consider a gamma-cisternogram when CSF rhinorrhea is a possibility and the patient is unable to produce any fluid for testing for beta2-transferrin. This test is very sensitive for finding a CSF leak, but, while it may indicate which side of the nose is involved, it is not particularly good for further identifying the site of an identified leak. It involves injecting a radioactive isotope into the CSF. Cotton pledgets are placed in the nasal cavities, and, after an appropriate time interval, these are removed and tested for radioactivity. The presence of radioactive material on the cotton pledgets indicates CSF rhinorrhea.

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Diagnostic Procedures

Consider performing a forced duction test to assess the mobility of the globe to determine if entrapment of extraocular muscles exists.

Consider performing a traction test on the medial canthal ligaments to assess the stability of the ligaments and their bony attachments.

Obtain an ophthalmology consult to assess the globe and orbital contents as well as for visual acuity testing on any patient who has sustained periorbital or orbital trauma. Visual field testing may also be indicated.

Olfactory testing is usually performed fairly grossly, though formal testing is possible if indicated.

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