Supraorbital approach for repair of open anterior skull base fracture

Case report

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To the authors' knowledge, this is the first report of the use of anterior orbitotomy via the supraorbital eyelid crease to repair a dural tear caused by an orbital roof fracture. When transorbital penetrating injuries occur in children, they are commonly caused by accidental falls onto pointed objects. The authors report on their experience with a 7-year-old girl who fell onto a blunt metal rod hanger that penetrated her left eyelid, traversed superior to the eye globe, and penetrated the orbital roof at a depth of 3–4 cm, lacerating the dura mater and entering the cerebrum. An anterior transpalpebral transorbital approach was used to perform the microsurgical anterior skull base and dural repair. The authors advocate the application of this approach to orbital roof fractures because it provides excellent access to the orbital roof, eliminates the need for more invasive craniotomy, results in a small and well-hidden scar in the eye crease, and overall offers a shorter recovery time with less psychological stress to the patient.

Abbreviations used in this paper: CSF = cerebrospinal fluid; ED = emergency department.

Article Information

Address correspondence to: Raphael Guzman, M.D., Division of Pediatric Neurosurgery, Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5327. email: raphaelg@stanford.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    A: Photograph of the patient on presentation to the ED with a metal rod protruding from the superior aspect of her left eye. B: Plain film lateral radiograph demonstrating the foreign object penetrating through the superior aspect of the orbit. C: Coronal CT reconstruction demonstrating skull base fracture and pneumocephalus (arrow). D: Aquarius 3D reconstruction of face. Red arrow indicates site of skull base fracture.

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    A: Schematic of incision used in the suprorbital approach. B: Intraoperative photograph demonstrating periorbital structures on approach to the fracture. C: Intraoperative photograph demonstrating skull base fracture and durotomy during removal of bone fragment (arrow indicates fracture leading into durotomy and frontal lobe tissue).

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    Postoperative photographs of the patient obtained immediately after surgical closure (A) and 6 weeks after surgery (B). Sagittal (C) and coronal (D) reconstructions of a CT scan obtained 6 months after surgery showing the bone defect (arrow) but no signs of a growing fracture compared with the initial CT scan.

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