Traumatic Nonmissile Penetrating Transnasal Anterior Skull Base Fracture and Brain Injury with Cerebrospinal Fluid Leak: Intraoperative Leak Detection and an Effective Reconstruction Procedure for a Localized Skull Base Defect Especially After Coronavirus Disease 2019 Outbreak

World Neurosurg. 2020 Aug:140:166-172. doi: 10.1016/j.wneu.2020.05.236. Epub 2020 Jun 1.


Background: Cerebrospinal fluid (CSF) leakage after penetrating skull base injury is relatively rare compared with close head injuries involving skull base fractures.

Case description: We report the case of a 65-year-old man who had presented with epistaxis and serous rhinorrhea. When he had fallen to the ground near his bee boxes, a garden pole had poked into his right nostril. He had instantly removed the pole from his nostril himself. However, immediately after removal of the pole, he had developed nasal bleeding and serous rhinorrhea. He then drove to our emergency room. Computed tomography showed pneumocephalus with a minor cerebral contusion in the left frontal lobe and a penetrating injury in the left anterior skull base. His CSF leakage had not resolve spontaneously within 1 week after the injury with strict bed rest. We repaired the CSF leakage using a fat (adipose tissue)-on-fascia autograft plug and caulked the defect in the anterior skull base with the fat-on-fascia graft (FFG) plug through the left nostril with endoscopic guidance. The CSF rhinorrhea was successfully controlled. Intranasal local application of fluorescein aided in the detection of the direction of flow of the CSF leakage.

Conclusions: Endonasal endoscopic caulking of a skull base defect using an FFG plug can be useful to treat CSF leakage due to the localized skull base defect, especially in the coronavirus disease 2019 pandemic. It is simple, inexpensive, and timesaving. It requires no special skills nor sophisticated instruments that can cause aerosolization, reducing the risk of infection during the surgery.

Keywords: COVID-19 era; Cerebrospinal fluid leakage; Endonasal endoscopic repair; Fat-on-fascia graft; Fluorescein; Skull base defect; Traumatic nonmissile penetrating transnasal skull base fracture.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Betacoronavirus / pathogenicity*
  • Brain Injuries / surgery*
  • COVID-19
  • Cerebrospinal Fluid Leak / etiology*
  • Coronavirus Infections*
  • Humans
  • Male
  • Nasal Cavity / surgery
  • Nasal Cavity / virology
  • Pandemics*
  • Plastic Surgery Procedures / methods
  • Pneumonia, Viral*
  • SARS-CoV-2
  • Skull Base / surgery*
  • Skull Fractures / surgery*