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Frontal Sinüs ve Kafa Tabanı Kırıklarına Tanısal Yaklaşım ve Tedavi
Diagnostic Approach and Management of Frontal Sinus and Skull Base Fractures
Dr. Cem MEÇOa,b, Dr. İrfan YORULMAZa
aKulak-Burun-Boğaz, Baş ve Boyun Cerrahisi AD, Ankara Üniversitesi Tıp Fakültesi, ANKARA
bKulak-Burun-Boğaz, Baş ve Boyun Cerrahisi AD, Salzburg Paracelsus Üniversitesi Tıp Fakültesi, AVUSTURYA
Turkiye Klinikleri J E.N.T.-Special Topics. 2008;1(4):51-61
Article Language: TR
ÖZET
Frontal sinüs kırıkları ön ve arka duvar kırıkları olmak üzere iki ana grupta değerlendirilir. Ayrıca, kırık hattının frontal sinüs dışa akım yolunda obstrüksiyona yol açıp açmadığı da önemlidir. Ön duvar kırıkları daha çok estetik deformiteler yaratırken, arka duvar kırıkları intrakraniyal ve dural yaralanma ile beyin omurilik sıvısı (BOS) kaçakları gibi yaşamı tehdit edebilecek durumlarla sıkça beraber görülürler. Yüksek rezolüsyonlu multiplanar bilgisayarlı tomografi (BT) frontal sinüs kırıklarının karakter ve yaygınlığının değerlendirilmesinde en iyi yöntemdir. Tedavide estetik kaygılar yanında, intrakraniyal yapıların korunup BOS kaçağının kontrolü ve geç komplikasyonların engellenmesi esastır. Günümüzde osteoplastik flepler ile frontal sinüs obliterasyonu veya kraniyalizasyonu en güvenli tedavi yaklaşımını oluşturmaksa da, uygulanan modern endonazal endoskopik teknikler geleneksel tedavi yaklaşımlarında modifikasyonlara sebep olmaktadır. Diğer yandan frontal sinüs arka duvarı ve tüm ön kafa tabanı boyunca oluşan kırıklarda dura yırtığı ve BOS rinoresi oluşma ihtimali vardır. Bunlar menenjit ve beyin apsesi gibi yaşamsal komplikasyonlara sebep olabileceklerinden optimum tedavileri gerekmektedir. Modern ve güvenilir BOS testleri (ß2-transferrin, ß-trace protein ve sodyum fluorescein testleri) ve görüntüleme yöntemleri (BT ve manyetik rezonans sisternografi) tanısal algoritmalar dahilinde kullanılarak kesin tanı ve tedaviyi yönlendirir. Tespit edilen dural yırtıklar uygun ekipman, teknik ve greftler kullanılarak onarılır. Sızıntısız bir tamir yapıldığı postoperatif dönemde yine objektif testlerle kontrol edilmelidir.

Anahtar Kelimeler: Frontal sinüsler, kafa tabanı, kafa travması, frontobasilar kafa kırığı, serebrospinal sıvı rinoresi, tanı, tedavi
ABSTRACT
Frontals sinus fractures are evaluated in two major groups as anterior and posterior table fractures. Besides, obstruction at nasofrontal outflow due to injury is another important issue. Anterior table fractures usually source aesthetic deformities, while posterior table fractures frequently associate with life-threatening intracranial or dural injuries and cerebrospinal fluid (CSF) leaks. The best method for assessing extends and characteristics of frontal sinus fractures are multiplanar high resolution computed tomography (CT). Nearby correction of aesthetic deformity, therapy is focused on protection of intracranial structures, cessation of CSF fistula and prevention of late complications. Frontal sinus obliteration or cranialization still remains to be the safest management of frontal sinus fractures, though modern endonasal endoscopic techniques being used today have caused modifications on traditional treatment protocols. Furthermore dural tears and CSF rhinorrhea could occur at fractures along the whole skull base including the frontal sinus posterior table. These require optimum treatment as they could cause vital complications like meningitis and brain abscess. Modern and reliable CSF tests (ß2-transferrin, ß-trace protein and sodium fluorescein tests) and imaging methods (CT and magnetic resonance cisternography) are being used in diagnostic algorithms that guide definitive diagnosis and treatment. Detected dural tears are repaired by using appropriate instruments, techniques and grafts. Postoperative water-tight closure should be controlled by objective tests.

Keywords: Frontal sinuses, skull base, craniocerebral trauma, frontobasilar skull fracture, cerebrospinal fluid rhinorrhea, diagnosis, treatment

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30.03.2014

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