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v. Self-Seal after Reduction of the Fractures

Most CSF leaks at the level of the cribriform plate will self-seal after

reduction of the fractures. Consideration may also be given to placing

the patient in the semi-upright position and inserting an epidural drain.

For persistent leaks, an endoscopic approach to repair is usually

successful.

H. Prevention and Management of Complications

1. Indications for Antibiotics

Indications for antibiotics include any fractures that violate the integrity

of the nasal or sinus mucosa, cause a pathway from the sinuses to the

orbit or intracranial contents, or are present in a CSF leak. Since

clinicians disagree about the use of antibiotics in small CSF leaks,

residents should discuss this subject with their attending

otolaryngologists.

A broad-spectrum antibiotic should be chosen. which is effective

against the usual nasal and sinus pathogens. Special consideration

should be given to patients who have a history of chronic or recurrent

sinusitis with respect to the potential presence of drug-resistant

organisms.

Antibiotic coverage need not extend past 5–7 days, unless the wounds

become infected or an acute ethmoid or frontal sinusitis is detected.

2. CSF Leaks

As discussed above in section II.B.2.g, most CSF leaks will spontane-

ously resolve after repair of the NOE fractures. However, it may be

necessary to repair the defect with an endoscopic tissue patch, septal

flap, or anterior cranial fossa approach to the cribriform plate region

with a dural patch or pericranial flap. CSF rhinorrhea due to a posterior–

inferior frontal sinus-displaced fracture may be treated by obliteration

of osteoplastic frontal sinus fat.

3. Corneal Injuries

A corneal laceration as a result of the blunt trauma will normally be

managed by the ophthalmologist, and could delay the repair of NOE

injuries until the specialist is satisfied that the cornea is healing satis-

factorily. Abrasions are less likely to delay the repairs, but the ophthal-

mologist will likely wish to protect the cornea from further, inadvertent

injury during the surgical procedure. Typically this will be achieved by

placing a corneal protector on the globe before the surgery and remov-

ing it at the end of the surgery. Even in the absence of any corneal