Carotid-cavernous sinus fistula complicating a complex shotgun facial injury

Carotid-cavernous sinus fistula is a rare but major complication of severe head injuries. This pathological communication between the internal carotid artery and the surrounding cavernous sinus at the base of the skull may result in marked retinopathy, optic atrophy with permanent loss of vision, and, rarely, fatal epistaxis. Physical signs of this entity are pathognomonic and include marked chemosis, pulsating exophthalmos, and a pulse-synchronous supraorbital bruit. Diagnosis is confirmed by carotid angiography or computed tomography scan. Treatment modalities range from internal carotid ligation to catheter embolectomy and, at times, observation. A patient with carotid-cavernous sinus fistula following complex facial trauma is described. The differential diagnosis and management of this rare pathological entity is discussed. In their position as primary consultants of head and neck trauma, plastic and reconstructive surgeons should be aware of both the diagnosis and management of this unusual condition.