Skull base trauma: Diagnosis and management

Madjid Samii*{ and Marcos Tatagiba*

*Department of Neurosurgery, Hannover College of Medicine, { Nordstadt Hospital, Hannover, Germany

The singular anatomical relationship of the base of the skull is responsible for the particular problems that
may arise after injury. Extensive dural laceration and severe neurovascular damage may accompany skull
base injuries. Trauma to the anterior skull base is frequently related to the paranasal sinuses, and trauma to
the middle and the posterior skull base usually affects the petrous bone. Injury to the anterior fossa
including the paranasal sinuses may produce CSF leakage, damage the olfactory nerves, optic nerves, and
orbita contents. Fractures may affect the carotid canal, injure the internal carotid artery and result in
carotid–cavernous Žstula. Trauma to the petrous bone may cause facial palsy and deafness, and CSF
leakage with otorrhoea or paradoxal rhinoliquorrhoea. Trauma to the posterior fossa may lacerate the major
venous sinuses, and affect the cranio–cervical stability. Each one of these injuries will need a particular
strategy. Decision making for management as a whole must consider all aspects, including the fact that
these injuries frequently involve polytraumatized patients. Decisions regarding the timing of surgery and
the sequence of the surgical procedures must be made with great care. Modern surgical techniques and
recent technologies including functional preservation of the olfactory nerves in frontobasal trauma, visual
evoked potentials, assisted optic nerve decompression, facial nerve reconstruction, interventional
technique for intravascular repair of vascular injuries, and recent developments in cochlea implants and
brain stem implants, all contributed signiŽcantly to improve outcome and enhance the quality of life of
patients. This article reviews basic principles of management of skull base trauma stressing the role of these
advanced techniques. [Neurol Res 2002; 24: 147–156]

Keywords: Anterior skull base; CSF leak; internal carotid artery; olfactory tract; trauma

INTRODUCTION operation between neurosurgeons, neuroradiologists,

In primary head trauma different associated injuries may ENT surgeons, and maxillo–facial surgeons. Several
coexist, including skull fractures, focal injuries (brain major related structures may be affected at the cranial
contusions, intradural or extradural hematomas), and base. At the anterior skull base, the paranasal sinuses
diffuse axonal injury, depending on the mechanism of and the orbit are commonly involved. In the middle
trauma1 . Associated fractures of the base of the skull are fossa, the cavernous sinus and the intracavernous
frequent Žndings in severe head trauma. A differentia- internal carotid artery may be damaged by bone
tion is done whether the injury is caused by blunt or fragments resulting in carotid–cavernous Žstula. The
penetrating injury. Blunt trauma is responsible for over petrous bone is frequently affected when the middle and
90% of all skull base fractures2 , with the penetrating posterior skull base are both involved. Laceration of
injuries such as gunshot being much less common. major venous sinuses and cranio–cervical instability are
Understanding the mechanisms of injury and related typical complications of trauma to the posterior fossa.
problems is essential for managing complications in In this review article the authors divide for didactic
skull base trauma. reasons the issue of skull base trauma into four major
The injury may vary from one harmless solitary small areas: trauma to the anterior skull base associated with
linear fracture to very complex craniofacial damage with the paranasal sinuses, trauma to the middle skull base
associated brain contusions, intracranial hematomas, associated with the petrous bone, trauma to the posterior
dural tear and vascular injury (Figure 1). Developments skull base, and trauma to the cranio–cervical junction.
in diagnostic tools such as powerful high-resolution
computerized tomography (CT) and intensive care
cerebral monitoring have added very much to the pool TRAUMA TO THE ANTERIOR SKULL BASE
of information in the skull base injured patient. Trauma to the anterior skull base is frequently associated
Skull base trauma poses particular problems in with injury to the paranasal sinuses and the orbit with its
diagnosis and treatment. On one hand, even a small contents (Figure 2). Associated injury of the face
linear fracture may be overlooked at CT scan and remain affecting bone and soft tissue is found in over 50% of
unnoticed until it causes CSF leak or produces the patients.
meningitis. On the other hand, complex craniofacial The mechanism of trauma of the anterior cranium
fractures will require a close interdisciplinary co- frequently involves vehicular accidents with unre-
strained passengers. Sixty-one percent of patients who
Correspondence and reprint requests to: Marcos Tatagiba, MD, PhD, needed surgery for anterior cranial base trauma in our
Associate Professor, Department of Neurosurgery, Hannover College of Department had primary coma3. The injury usually
Medicine, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany.
[[email protected]] Accepted for publication produced fractures of the forehead, orbit roof and
September 2001. anterior base with involvement of the cribriform plate.

# 2002 Forefront Publishing Group Neurological Research, 2002, Volume 24, March 147
0161–6412/02/020147–10
Anterior skull base trauma: Madjid Samii et al.

Figure 1: Severe intracranial trauma with involvement of the anterior skull base. Left, note several intradural air
inclusions. Right shows subgaleal hematoma (large arrow), small epidural hematoma (small arrows), and intracerebral
bleeding. In addition, prepontine subarachnoidal bleeding and air inclusions

Frequent clinical signs of frontobasal injury include used under minimally invasive endoscopic technique5 ,6 .
epistaxis, proptosis, chemosis, rhinorrhea, anosmia and By using special Žlters or UV source, uorescein-
visual deŽcits. At the time of patient admission into the embedded CSF will give a greenish shine.
hospital, an initial joint consultation should be held to Radiological studies play a signiŽcant role in the CSF
decide which special diagnostic investigations are leak investigation. Noncontrast high-resolution CT
necessary. Plain X-ray Žlms of the head and cervical showed a defect in 70% of the patients with CSF leak
spine are mandatory as initial investigations. A standard in the series of Stone et al.4 . CT cisternography study
CT investigation is performed Žrst to rule out large may detect a CSF Žstula without previous visualization
intracranial hematomas, which is followed by a high- of a defect on high-resolution CT (Figure 3).
resolution CT investigation with Žne slices (up to 3 mm)
of the skull base with bone algorithms and coronal Timing of surgical treatment
reformations. Approximately 70% of the patients with Acute surgery is not always indicated. The timing of
CSF leakage show bone defects at high-resolution CT4 . the operative treatment will depend on the patient’s
Routinely, magnetic resonance imaging (MRI) is not general condition, the presence of life-threatening
included in the intitial investigations. intracranial hematomas, type of injury (opened or
closed), and signs of optic nerve compression. CSF
CSF leakage leakage will need early treatment, usually within the Žrst
Among 625 patients with severe cranial base trauma 1–2 weeks, while the patient is kept under antibiotic
therapy. A closed trauma with no CSF leak and no
who underwent surgical treatment in our Department
intracranial or intra-orbital mass is managed at the
from 1986 to 1994, only 75 patients (12%) had CSF
leakage3. An initial CSF leak can stop spontaneously intensive care unit. Thorough diagnostic investigations
are essential for adequate surgical planning, and should
within the Žrst days due to clotted blood, lacerated
be carried out prior to any urgent surgical treatment.
mucosa or prolapsed brain. Sometimes several tests will
be necessary to rule out a latent CSF Žstula, including In anterior skull base injury, the choice of the
approach must meet following criteria:
clinical examinations under valsalva maneuver, glucose
test strip, measurement of b2 -transferrin, isotope inves- 1. Provide wide exposure of the dural defect.
tigations, and uorescein test. Intrathecal uorescein 2. Treat associated intracranial injuries.
application has been proven very useful in detecting the 3. Involve a minimum of surgical stress.
leakage site even in very small CSF amount. It can be 4. Preserve the olfactory sense.

148 Neurological Research, 2002, Volume 24, March

 Anterior skull base trauma: Madjid Samii et al.

Transfrontal extradural approach

The patient is positioned in supine position with
elevated trunk, and the head extended by 15° –20° , and
Žxed on the MayŽeld head holder. Following a
bitemporal coronal skin incision a unilateral or bifrontal
craniotomy is chosen, depending on the extent of the
fractures. An opened frontal sinus is carefully cleaned
out of mucosa and packed with antibiotic gauze. In the
bifrontal approach, the dura is mobilized on both sides
of the crista galli and in part sharply elevated from the
cribriform plate. By this maneuver, a clear delineation of
the anterior skull base is possible. Fragments of bone are
re-adapted at the skull base or removed. This approach
also permits a good exposure of the frontal sinus,
ethmoid cells, and sphenoid sinus, supplemented if
necessary by removal of the crista galli itself. Further-
more, this method offers good exposure of the optic
canal and the superior aspect of the orbital contents. The
optic chiasm with the intradural portion of the optic
nerve is not visualized by this approach. To decompress
the optic nerve, the orbit roof can be drilled at the area
of the optic canal, as discussed below. Dural defects are
repaired. The endocranium is sealed off against the
frontal sinus with a galea-periosteal ap that has a basal
pedicle.

Transfrontal intradural approach

Basically, two methods can be used to expose the
intradural contents of the anterior cranial fossa: via a
bifrontal craniotomy or a unifrontal craniotomy. To
repair extensive anterior skull base fracture with dural
laceration the bifrontal approach is preferred. Following
a bifrontal craniotomy, the dura is opened close to the
base and the superior sagittal sinus, which is ligated and
divided. The arachnoid cisterns are opened progres-
sively as the frontal lobe is gently retracted. If the
olfactory nerves are not completely damaged by the
trauma, they are preserved by carefully dissecting them
away from the cortical surface (Figure 4). At this time it
will be possible to delineate the entire involved area of
dura on the skull base. If necessary, the orbital roof is
decompressed by removing bone fragments. The optic
canal can be opened by drilling the orbit roof, thus
decompressing the optic nerve. Then a pedicled galea–
periosteal ap is taken and mobilized to cover the
frontal base. The ap can be split to surround the
olfactory nerves, before it is sutured at the dural layer of
Figure 2: Severe anterior skull base trauma as shown at bone window the frontal base (Figure 5). The sutures are then
CT. Note the involvement of the ethmoidal cells (above), the orbit reinforced with Žbrin glue. The operation concludes
(middle), and the frontal sinus (below) with dura closure and Žxation of the bone ap. Bone
fragments are Žxed with suture material or with
miniplates.

To preserve the olfactory sense the surgical exposure is

done transfacially or by a subfrontal intradural Transfacial approaches
approach7 . The subfrontal extradural approach to the Circumscribed bony and dural defects involving the
anterior skull base involves division of the olfactory posterior wall of the frontal sinus and areas of the skull
Žbers at the cribriform plate when the dura is elevated. base bordering on the sphenoid and ethmoid sinuses,
This technique is acceptable when there is anosmia pre- the ‘rhinosurgical fronto–orbital approach’, is preferred8 .
operatively. The rhinosurgical technique is especially suitable for

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Anterior skull base trauma: Madjid Samii et al.

Figure 3: CT cisternography with coronal slices (left) shows a small CSF Žstula (right, arrow) at the area of the olfactory
groove

Injury of the orbit

Although any part of the orbit can be fractured during
a facial trauma, orbital oor fractures involving the thin
maxillary bone are very common. Clinical Žndings
include orbital hematoma, enophthalmos, and diplopia.
Visual deŽcits up to blindness may be caused by direct
compression of the optic nerve by bone fragments,
hematoma or foreign bodies, or indirect compression
due to increased ocular pressure. Although the prognosis
is poor when complete blindness has been set up10 ,
surgery is indicated to decompress the optic nerve when
there is an obvious compression8 . Recently, the role of
electrophysiological investigation by ash-evoked visual
potentials (VEP) and the electroretinogram (ERG) has
been stressed as reliable electrophysiological methods to
gather speciŽc information as to whether the visual
pathway function is altered11 . Surgery has been indi-
cated based on electrophysiological and radiological
Figure 4: Intra-operative photograph of bifrontal intradural exposure of (CT scan) Žndings, and includes decompression of the
a severe dural tear of the anterior fossa. The olfactory nerve (large orbital compartment in case of retrobulbar hematoma or
arrow) was dissected away from the brain surface (two small arrows). decompression of the intracanalicular part of the optic
The border of the dural tear is shown (three middle-size arrows). The
bony surface of the planum sphenoidale (*) is demonstrated
nerve in the traumatized optic canal or posterior orbit.
Intravenous megadosis of methylprednisolone is started
as soon as possible11,12 .
repairing CSF leak through the sphenoid sinus and for Two main surgical techniques are used to decompress
optic nerve decompression (Figure 6). the optic nerve: the transethmoidal and the transfrontal
Recently, developments in endoscopic technique approach8 . Other techniques include the transnasal or
have allowed in a number of cases permanent repair transethmoidal use of endoscopic techniques such as
of dural injury by the endonasal approach5,6,9 . the combined transconjunctival/intranasal endoscopic

150 Neurological Research, 2002, Volume 24, March

 Anterior skull base trauma: Madjid Samii et al.

opened by removing the medial wall from anterior to

posterior. Bone fragments are removed. Finally, the
dural sheath can be split to produce additional decom-
pression if necessary. The transfrontal approach is used
when concomitant frontobasal injury must be treated.
Following a unilateral or bifrontal craniotomy the dura
over the orbit roof is elevated and the frontal lobe
retracted. Then bone fragments are removed and the
optic canal is opened by drilling the apex of the orbit
roof. When the exposure reaches the orbital apex, the
dural sheath is split to decompress the nerve. Dural tear
over the orbit roof are treated as described above.

Facial trauma
There is consensus among maxillo–facial surgeons
that fractures of facial bones must be treated within the
Žrst 1–2 weeks after trauma8,14 . Acute primary recon-
struction is rarely necessary, and most surgeons prefer to
wait until severe soft tissue swelling has reduced. In
small children, deŽnite repair is done earlier, within the
Žrst 3–4 days, because of the rapid consolidation of the
bone fractures in that age. In combined cranio–facial
fractures, when primary acute neurosurgical treatment is
needed due to any life-threatening reason, the neuro-
Figure 5: Vascularized galea–periosteal ap without (above) and with
preservation (below) of the olfactory nerves. The technique is detailed surgeon will need to reconstruct the usually fractured
on the small picture right. The galea ap is sutured at the intact dural bone of forehead and orbit roof primarily. Otherwise,
layer of the anterior fossa close to the nerve on both sides the co-operation with maxillo–facial surgeons is strongly
recommended.

TRAUMA TO THE MIDDLE SKULL BASE

Trauma to the middle skull base, the so-called latero-
basal injury, is usually characterized by signs of fracture
of the petrous bone. Clinical signs include the post-
auricular hematoma (Battles sign), hematotympanum,
othorrhoea, facial palsy, vertigo and tinnitus. The clivus
may be included in the trauma, which may result in
palsy of the cranial nerve VI (Figure 7). Injury to the
middle ear with disruption of the ossicular chain will
produce conductive hearing loss, which must be
differentiated from hearing loss caused by damage to
the inner ear and to the cochlear nerve, as discussed
below.
Key anatomical landmarks of the middle fossa
include1 5,16 : the foramen spinosum with the middle
meningeal artery anteriorly; the arcuate eminence,
posteriorly; the petrous carotid artery, which is mostly
only partially covered by a thin bone; the superior
petrosal sinus, which runs along the medial border of the
upper surface of the petrous bone. The greater petrosal
Figure 6: Rhinosurgical approach to the anterior fossa and the optic
nerve passes below the lateral margin of the trigeminal
canal
ganglion. Drilling along the course of the greater
petrosal nerve in dorsal direction exposes the geniculate
approach to the optic canal described by Kuppersmith et ganglion, which can be followed in medial direction to
al.1 3. For the transethmoidal approach, a skin incision is expose the labyrinthine portion of the facial nerve until
made beneath the brow followed by removal of the its course into the internal auditory canal.
frontal process of the maxilla and opening the oor of Petrous bone fractures may have a transverse of a
the frontal sinus. The ethmoidal cells are exposed and longitudinal trajectory. The longitudinal fractures are
exenterated along the cranial base. The lamina papyr- found three times more frequently than transverse
acea is then removed up to the orbital apex. With ones17 . To access the exact pattern of fracture,
microscopical technique, the optic canal is progressively radiological investigations are crucial. Although plain

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Anterior skull base trauma: Madjid Samii et al.

structures such as the labyrinth block, and the facial

nerve. Resulting symptoms include inner ear hearing
loss, severe vertigo, nystagmus, and facial palsy. The
extension of the transverse fracture towards the jugular
foramen may cause additionally lower cranial nerve
deŽcits. From 44 patients with laterobasal injury,
Schilling et al.17 found in 33 cases a longitudinal
fracture, in seven cases a transverse fracture, and in
four cases combined fractures. Facial palsy was much
more frequent in transverse fractures ( 3/7) than in
longitudinal ones (7/ 33). Deafness was found in four of
seven transverse fractures, but only once in 33 longi-
tudinal fractures.

Surgical treatment
Immediate or early surgical treatment is indicated for
open depressed fractures with or without dural injury
and for expanding intracranial (epidural, subdural or
intracerebral) hematoma. Due to the proximity of the
temporal lobe to the brain stem and the risk of uncal
herniation, surgical decompression must not be delayed
in these cases. Secondary surgical treatment is indicated
in CSF Žstula and facial nerve damage.
CSF Žstula may be observed as otorrhoea or as
paradoxal rhinorrhoea, as a result of dural injury
associated with injury to the middle ear. Treatment
consists of exposure of the site of dural defect and
closing it. Surgical approach is chosen based on data
obtained by accurate thin CT slices with bone algo-
rithms. Basically, there are two main approaches: a
transcranial, subtemporal approach to the middle fossa,
and a transmastoid approach, though both approaches
can be combined if necessary8 .
The subtemporal extradural approach to the anterior
petrous bone is done with the patient’s head parallel to
horizontal line and slightly extended. A temporal
craniotomy anterior to the ear and above the zygoma
is performed. The dura is elevated from the oor of the
middle fossa until the anterior surface of the petrous
bone is exposed, revealing the fracture line. The arcuate
eminence and the greater petrosal nerve are visualized.
Dural retraction is maintained using a Fisch retractor
(Figure 9). IdentiŽcation of internal auditory canal
involves drilling following the greater petrosal nerve,
which indicates the geniculate ganglion. At this point
Figure 7: Multiple fractures of the clivus. Above, bilateral fractures and
additional fracture of the condyle right. Below, fracture of the clivus on
the drilling is turned medially to expose the labyrinthine
the midline portion of the facial nerve until the fundus of the internal
auditory canal. If present, bone fragments are removed
from the fallopian canal. This can be opened over a
radiography is still used as a primary diagnostic tool, longer extension to reconstruct the facial nerve with
high resolution CT scan with bone algorithms will sural graft in case of facial transection by the fracture.
delineate precisely the extension of the damage in this Dural injuries are repaired with muscle from the
complex area of the skull (Figure 8). Longitudinal temporal muscle and Žbrin glue. In case the dura has
fracture of the petrous bone usually follows a fracture been opened to remove intradural hematomas, dural
of the temporal squama, and projects through the middle repair is done intradurally. Then, muscle graft is used to
ear. It may produce rupture of the tympanum and injury plug bone defects, the craniotomy is Žxed and the
to the facial nerve, which may result in hematotympa- wound is closed.
num, othorrhoea, conductive hearing loss, and (less For the transmastoid translabyrinthine approach,
frequently) facial palsy. Transverse fracture of the decortication of the mastoid and removal of most
petrous bone usually follows a posterior fracture from mastoid air cells exposes the middle fossa plate and
the occipital bone. It frequently damages the inner ear the superior petrosal sinus superiorly, the anterior

152 Neurological Research, 2002, Volume 24, March

 Anterior skull base trauma: Madjid Samii et al.

Figure 8: Multiple fractures of the petrous bone. The left picture shows the fractures in detail, which affect the petroclival
junction, the geniculate ganglion area and the jugular foramen

Figure 9: Subtemporal extradural approach to the petrous bone

portion of the sigmoid sinus posteriorly, and the plate with fat tissue or muscle and Žbrin glue. If the facial
covering the labyrinth block and facial nerve anteriorly nerve is damaged over a long extension within the bone,
(Figure 10). The fallopian canal is opened to decompress the dura of the posterior fossa is opened and a central
the facial nerve or to repair it. The cavity is then closed stump of the nerve is identiŽed at the brain stem. Then

Neurological Research, 2002, Volume 24, March 153

Anterior skull base trauma: Madjid Samii et al.

Figure 10: Retroauricular transmastoid approach to the facial canal and the labyrinth block

an intracranial–intratemporal facial repair (Samii’s tech- TRAUMA TO THE POSTERIOR SKULL BASE
nique) is performed using sural nerve graft8 . Fractures of the petrous bone, principally the transverse
ones, may extend to the occipital bone and affect the
posterior fossa. Laceration of major venous sinuses such
Treatment of hearing loss as the sigmois sinus and the jugular bulb will result in
Deafness due to bilateral petrous bone fracture is a posterior fossa venous epidural hematoma. The hema-
disastrous phenomenon. The cause is usually a destruc- toma may not be apparent at Žrst CT examination and
tion of the cochlea by the fracture, or rarely, a disruption may develop rapidly within an interval of a few hours.
of the cochlear nerve. In cases of cochlear damage, very Repeated CT investigation is necessary to exclude this
acceptable hearing function can be restored by the use complication, particularly in comatose patients.
of cochlea implants1 8 . In the rare cases of bilateral Immediate surgical decompression of the bleeding is
cochlear nerve damage, it is now possible to restore mandatory with sinus repair. The jugular foramen may
some hearing function by the use of brain stem implants be involved in the injury as well. Damage to the lower
(ABI), which directly stimulate the cochlear nucleus at cranial nerves may produce severe deŽcits including
the brain stem19,20 . dysphagia. The treatment usually involves tracheostomy
and rehabilitation of swallowing function in specialized
Treatment of vascular injuries centers.
Different vascular injuries involving the internal
carotid artery such as carotid cavernous Žstula2 1,22 TRAUMA TO THE CRANIO–CERVICAL JUNCTION
(Figure 11) and arterial wall dissection2 3 can result from Injury to the cranio–cervical junction may occur isolated
the laterobasal injury. The treatment of carotid caver- as pure cervical spine trauma, or accompany a complex
nous Žstulas has undergone a fundamental transforma- skull base trauma. The injury may involve bone,
tion during the last three decades. Endovascular ligaments and vascular structures. Several types and
techniques have not only largely replaced surgical subtypes of fractures of the occipito–atlanto–axial
management of this disease, but they have also resulted complex have been described. Radiological investiga-
in substantially lower rates of procedure-associated tions include besides plain X-ray Žlms a bone window
morbidity and mortality22 . The treatment of carotid or CT scan, and sometimes MRI. Management may be
vertebral artery dissection is usually a conservative one difŽcult in some cases. Indication for surgery will largely
with anticoagulant therapy. Surgical treatment is indi- depend on the presence or not of neurological deŽcits,
cated in exceptional cases. and instability (bone, ligaments or both). Treatment

154 Neurological Research, 2002, Volume 24, March

 Anterior skull base trauma: Madjid Samii et al.

strategy includes reduction of the dislocation, decom- alar ligament. Because conventional X-ray Žlm exam-
pression of the neural structures and stabilization. It goes ination usually fails to show the fractures, thin slices or
beyond the scope of this article to describe all injury spiral CT studies are carried out with 2-D or 3-D
types in detail; instead, a summary of the most common reconstructions. Treatment is usually external Žxation
injuries is speciŽed along with their treatment. with collars.
Fractures of the occipital condyles are rare. They may
be associated with severe brainstem damage or with
moderate symptoms such as neck pain, difŽculty in
moving the neck, and deŽcits of the lower cranial
nerves, including the hypoglossal nerve. The condyle
fractures were divided into three types24 : I, fracture of
the condyle without dislocation of bone fragments; II,
skull base fracture that includes the condyle; III, severe
fracture with dislocated bone fragment by the ipsilateral

Figure 12: Severe cervical spine trauma with disrupture at the level of
Figure 11: MRI angiography of an ICA-cavernous sinus Žstula (arrows) C2–C3

Figure 1 3: Fracture of C2 body with dislocation of a bone fragment into the spinal canal

Neurological Research, 2002, Volume 24, March 155

Anterior skull base trauma: Madjid Samii et al.

The atlanto–occipital dislocation always represents a 4 Stone JA, Castillo M, Neelon B, Mukherji SK. Evaluation of CSF
severe trauma with disruption of the atlanto–occipital leaks: High-resolution CT compared with contrast-enhanced CT
and radionuclide cisternography. Am J Neuroradiol 1999; 20: 706–712
osseous–ligamentous complex, and it is fatal in the 5 Hughes RG, Jones NS, Robertson IJ. The endoscopic treatment of
majority of the cases25 . There may be an antero– cerebrospinal uid rhinorrhoea: The Nottingham experience.
posterior, or a longitudinal dislocation of the atlanto– J Laryngol Otol 1997; 111: 125–128
occipital junction. If the patient survives the trauma, 6 Wormald PJ, McDonogh M. ‘Bath-plug’ technique for the
endoscopic management of cerebrospinal uid leaks. J Laryngol
immediate cervical immobilisation with Halo is manda- Otol 1997; 111: 1042–1046
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from C0 to C2. olfactory nerve in skull base lesions. Skull Base Surgery. Proc 4th
Fractures of the atlas are divided into fractures of the Eur Skull Base Cong 1999; 9 (Suppl. 2): 40
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Approach, Heidelberg: Springer, 1989
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and involves fractures of both the anterior and posterior Otorhinolaryngol 1996; 36: 109–115
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