The management of dural tear resulting from mid-facial fracture

This study examines the relative risks and benefits of conservative and surgical management of dural tear secondary to middle third facial fracture and ascertains the type of skull and facial injury most often associated with the development of posttraumatic meningitis. Two projects were undertaken. First, the histories of 247 cases of major middle third facial fracture were reviewed with a recent follow-up of those patients who also sustained a dural tear. Second, 280 cases of bacterial meningitis were reviewed and particular attention was given to cases of posttraumatic meningitis. Of the 247 cases of middle third facial fractures studied, 43% (107/247) had evidence of a dural tear; of this group, 76 patients were managed conservatively and 31 patients were managed surgically. In the former group, there were three instances of recurrent cerebrospinal fluid rhinorrhea (CFR). In the surgically managed group, 77% (24/31) sustained surgical complications including two cases of posttraumatic meningitis and 21 cases of neurological deficit. Of the 280 cases of bacterial meningitis, 48 patients had sustained dural tear following trauma. The prognosis for posttraumatic meningitis is considerably better than for other forms of meningitis. The preceding trauma involved the vault of the skull in 90% (43/48) of cases, and discrete middle third facial fracture in one case (2.1%). Posttraumatic meningitis followed a previous operative repair in 15% (7/48) of the patients. The results of this study indicate that dural tear subsequent to middle third facial fractures is a different proposition than dural tear subsequent to direct skull trauma.(ABSTRACT TRUNCATED AT 250 WORDS)