Resident Manual of Trauma to the Face, Head and Neck

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

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