The Cranial Base Fracture after the Caldwell-Luc Operation.

Supplemental Digital Content is available in the text.

Sir:

There is a reputation that the face protects the brain from head injury.[1,2] However, less certain evidence exists that facial fractures prevent brain injury acting as a shock absorber, although there are many reports that facial fractures are a marker for increased risk of brain injury.[3-5] We report 2 meaningful cases of the sphenozygomatic fracture with history of the Caldwell-Luc operation for chronic sinusitis.

A 62-year-old man accidentally fell from approximately 3 m height, contused his right side face, and was immediately transported to our hospital. A primary examination revealed the right oculomotor and the partial vagal nerve palsy. Computed tomography (CT) showed the right frontal, sphenoidal, zygomatic, and maxillary fractures and the bilateral bone deformity of the maxilla as marks of Caldwell-Luc operation 30 years ago (Fig. 1) (See Supplemental Digital Content 1, which displays CT images of a 62-year-old man. The cranial base was fractured and the sphenoid sinuses were filled with blood or other liquid, http://links.lww.com/PRSGO/). His maxillary sinuses were less developed, and their function as a shock absorber may have been be lost.

Fig. 1.

3D CT image of a 62-year-old man who had an accidental fall. The overall displacement of the facial bones was not so serious, but their fragment was fractured en bloc with the cranial base.

A 70-year-old rider was injured and had a left zygomatic fracture with bilateral forearm fractures. The zygoma was comminuted and fractured with the greater wing of sphenoid (See Supplemental Digital Content 2, which displays a 3-dimensional CT image of the second case. The left zygoma was displaced with the sphenoid bone, http://links.lww.com/PRSGO/A122). His maxilla with history of the sinus operation was remodeled with the thickened bony buttress (Fig. 2). Thus, the traumatic force might be directly transmitted to the sphenoid bone.

Fig. 2.

A coronal CT image of a 70-year-old rider showed the sphenoid fracture, with the fluid collection in the sinuses. The pterygoid processes were abnormally thickened.

The facial bones are constructed with buttresses and thin paper-like bones around orbital, nasal, and paranasal cavities, which may serve a safety cushion to the brain. Because maxillary sinus operations result in lack of the paranasal mucosa and the anterior wall, the bony structure is rebuilt over time, and its function as a shock absorber of thin-wall cavities might be lost. In the first case, the external impact could be directly transmitted to the cranial base through the strengthened buttress, causing fractures and the temporal cranial nerve palsy. In the second case, the zygoma was broken in a so comminuted fashion that the impact was slightly absorbed and the damage of cranial base might be less than the first case. Their faces could not protect the brain at all.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. This work was supported by JSPS (Japan Society for the Promotion of Science) KAKENHI (Grants-in-Aid for Scientific Research) Grant Number 26670773. The article Processing Charge was paid for by the authors.