(Abstract) Objective: To explore the clinical value of nasal endoscopy in the management of nasocranial base trauma. 5 cases of nasal bone fracture combined with nasal septum fracture/dislocation 4 cases had good nasal septum correction in phase I surgery, with good nasal appearance and nasal ventilation, 1 case had left nasal congestion after surgery, and the nasal congestion disappeared after a month of transnasal endoscopic submucosal nasal septal resection. 2 cases combined with nasolacrimal duct rupture were cured in phase I surgery with the aid of nasal endoscopy Phase II treatment: 4 cases of maxillary sinus (anterior and superior wall) fracture The fracture of maxillary sinus (anterior and superior wall) in 4 cases, fracture of septal sinus in 2 cases, fracture of frontal septal sinus in 4 cases (2 cases with cerebrospinal fluid leakage), fracture of maxillary sinus septal sinus combined with fracture of orbital cardboard in 4 cases (2 cases with diplopia), fracture of pterygoid sinus in 6 cases (1 case with cerebrospinal fluid nasal leakage), all healed well after nasal endoscopic surgery with good alignment growth, no diplopia and visual impairment, normal eye movement, good shape, unobstructed sinus drainage, good epithelialization of nasal cavity and sinus. Among the 35 cases, one case of nasal haemorrhage died due to severe cerebral contusion although the nasal bleeding had stopped. Conclusion: The application of nasal endoscopy in the management of complex trauma of the nasal skull base can achieve more satisfactory results. Trauma to the nasal skull base is very common. The management of complex nasocranial base trauma with multiple sites such as nasal cavity, maxillary sinus, orbit and anterior middle skull base is very difficult, and if not treated timely, it often leaves nasal-facial deformity and obvious dysfunction or even death,. In recent years, we applied nasal endoscopy to successfully treat 35 cases of compound nasocranial base trauma and obtained good results. 1 Clinical data 1.1 General information Among the 35 patients, 25 were male and 10 were female; their ages ranged from 12 to 66 years old, with an average of 32.5 years old. All patients were admitted to the neurosurgery department of our hospital and were consulted by our department. The causes of trauma: 20 cases of car accident, 13 cases of brawl injury, and 2 cases of fall injury. The fracture sites were determined by specialist examination and CT scan: 3 cases of simple nasal bone fracture; 8 cases of nasal bone fracture and/or nasal septum fracture (2 cases combined with lacrimal duct rupture); 4 cases of maxillary sinus (anterior and superior wall) fracture; 6 cases of frontal septal sinus fracture (2 cases with cerebrospinal fluid leakage); 4 cases of maxillary sinus septal sinus fracture combined with orbital cardboard fracture (2 cases with diplopia). Six cases of fracture of the pterygoid septal sinus (one of them with cerebrospinal fluid nasal leakage). All patients had varying degrees of pain, local swelling, some petechiae, nasal congestion, and bloody fluid in the nasal cavity. Those with nasal bone and maxillary sinus fractures had localized swelling and deformation. All patients had different degrees of craniocerebral trauma including 19 cases of concussion, 9 cases of epidural hematoma, 7 cases of cerebral contusion , 15 cases combined with nasal haemorrhage. 1.2 Treatment 1.2.1 Routine treatment All cases were admitted to our neurosurgery department first and were treated by neurosurgery emergency. A (airway) is to ensure a smooth airway, remove foreign bodies such as blood, secretions, fracture fragments and dislodged teeth, and perform tracheal intubation or emergency tracheotomy if necessary. b (breathing) is to pay attention to respiratory management, observe respiratory status and blood oxygen changes. c (circulation) is to keep the circulatory system Boms means maintaining body heat, giving necessary oxygen inhalation, medications and surgeries. Combined thoracic and abdominal injuries were managed in collaboration with relevant departments. The surgery was performed in 20 cases within 24 hours, 20 cases after 1 week, and 5 cases were treated with emergency rhinorrhea and second-stage fracture. 1.2.2 Management of rhinorrhea For patients with bloody nose or small amount of rhinorrhea, under the premise of close monitoring of vital signs, only anti-infection and rehydration were given, and ear and nose blockage was prohibited. For patients with nasal hemorrhage that may cause hemorrhagic shock, on the premise of keeping the airway open, quickly aspirate the secretions, clots, blood, fracture fragments and foreign bodies in the oral nasal cavity with an aspirator to basically clarify the site of bleeding, compress the carotid artery if necessary, enter the operating room and perform nasal endoscopy under general anesthesia with transoral tracheal intubation, and with the help of 1% lidocaine and a little epinephrine cotton, the nasal endoscope is used to carefully find the site of bleeding while aspirating. The bleeding site was found by bipolar electrocoagulation with local microfilling (antibiotic gelatin sponge or Vaseline gauze on top of it). When no bleeding is found in the nasal mucosa but blood is present in the nasopharynx of the olfactory fissure, consider bleeding due to skull base fracture and perform the appropriate nasal tamponade (antibiotic gelatin sponge or Vaseline gauze on top of it). In case of severe nasal bleeding, it is often difficult to aspirate the bleeding quickly with a suction device. The posterior nostril should be filled. Monitor the cranial pressure closely and prepare for craniotomy to stop the bleeding, if necessary. Vaseline gauze was withdrawn after 48-72. (1.2.3.) Nasal bone/septum fracture (8 cases): 3 cases of nasal bone fracture alone and 5 cases of nasal bone fracture combined with nasal septum fracture/dislocation. Under nasal endoscopy, the torn mucosa was repaired, part of the dislocated cartilage was excised and then retracted, and the nasal bone was repositioned under direct vision at the same time. Two patients with combined nasolacrimal duct rupture were anastomosed by ophthalmologists under the microscope, and their placement was assisted by rhinologists with endoscopic direct vision. 1.2.4 Maxillary sinus fracture (4 cases) In 3 cases, the anterior wall of the maxillary sinus was opened through a Ko-Lu approach, the fracture site was searched for under the nasal endoscope, the displaced and subluxated fracture fragment was repositioned, the orbital contents were retracted, the embedded inferior rectus or inferior oblique muscle was released until there was no resistance to intraoperative traction on the eye, and the inferior nasal tract was opened under direct sinus endoscopy, and the maxillary sinus was filled with Vaseline gauze strips to support the repositioned orbital tissue. In the other case, an incision was made at the inferior orbital rim, and the fracture area was entered by separation below the periosteum of the orbital floor, and the subluxation tissue was loosened and repositioned, and an appropriately sized autologous septal bone was taken and placed on the orbital floor. 1.2.5 Septal sinus fracture (2 cases) Blood and fracture displacement in the septal sinus were obvious. The orbital contents were carefully retracted from the septal sinus with a striker, and the medial orbital periosteum and bone fragments were preserved and repositioned with some resistance, protected with gelatin sponge and fixed with iodoform gauze for 1 week. 1.2.6 Frontal sieve fracture (4 cases) Three cases had anterior and posterior frontal sinus wall (part of anterior skull base) fracture and sieve sinus fracture combined with cerebrospinal fluid leakage, two cases had intracranial pneumatosis, and the cerebrospinal fluid leakage did not improve after one month of conservative treatment, and fracture repair and cerebrospinal fluid leakage repair were performed. The fracture was repaired with a tipped frontalis osteochondral flap. 1.2.7 Fractures of maxillary and septal sinuses combined with orbital cardboard fractures (4 cases) Two of the four cases were associated with diplopia. The method was the same as that described above for maxillary septal sinus and septal sinus fractures. 1.2.8 Fracture of septal sinus (6 cases) 5 cases of fracture of medial septal sinus and anterior wall of septal sinus, 2 of them combined with orbital cardboard fracture, the treatment of septal sinus fracture was the same as above, the fracture of septal sinus without obvious displacement and complications was not treated. 1 case of fracture of septoparietal and parietal wall of septal sinus combined with cerebrospinal fluid leakage, the examination was septoparietal cerebrospinal fluid leakage. The open septal sinus was resected endoscopically, the bone at the edge of the fistula was scraped, and the fistula was covered with crushed muscle fragments and fascia, and the nasal passage was compressed with gelatin sponge and iodoform gauze. Postoperatively, all cases were treated with a combination of anti-inflammatory, hemostatic and hormonal therapy. One case of nasal haemorrhage was stopped but died on the third day of admission due to severe cerebral contusion. One case still had nasal bleeding and was again examined under nasal endoscopy and hemorrhage was stopped after bipolar electrocoagulation of the branch vessels of the pterygoid artery in the posterior segment of the lower nasal tract. Three cases of simple nasal bone fracture were treated by first-stage nasal endoscopy, and all of them had good nasal appearance and nasal ventilation. 5 cases of nasal bone fracture combined with nasal septum fracture/dislocation were treated by first-stage nasal septum correction in 4 cases, and had good nasal appearance and nasal ventilation. 1 case of postoperative left nasal congestion was detected, and the left deviation of the nasal septum was examined, and the congestion disappeared after transnasal endoscopic submucosal resection of the nasal septum 1 month later. Four cases of maxillary sinus fracture, two cases of septal sinus fracture, four cases of frontal septal sinus fracture, four cases of maxillary sinus septal sinus fracture combined with orbital cardboard fracture, and six cases of pterygoid septal sinus fracture were healed well with no diplopia and visual impairment, normal eye movements, good shape, unobstructed sinus drainage, and good epithelialization of nasal cavity and sinuses. Those with cerebrospinal fluid leakage had healed and no intracranial infection and other complications were observed. 3 Discussion For a long time, textbooks have emphasized that nasal bleeding and cerebrospinal fluid leakage in patients with skull base fractures should not be filled to avoid intracranial infection. For skull base fractures with hemorrhagic cerebrospinal fluid leak as the main manifestation, the textbooks routinely deal with them because the possibility of hemorrhagic shock is minimal and the main problems are cerebrospinal fluid leak and intracranial infection. Clinically, we often encounter severe skull base fractures where the patient has nasal hemorrhage, causing hemorrhagic shock for a short period of time, which is often life-threatening if not treated promptly. In clinical practice, this type of skull base fracture should be treated promptly with hemostasis and emergency tamponade. The cranial pressure should be monitored closely, and the patient should be prepared for craniotomy to stop the bleeding, if necessary. In recent years, with the wide development of nasal endoscopy, we applied nasal endoscopy to stop the bleeding in nasal cranial trauma, and found that the bleeding from skull base fractures traditionally considered are often combined with bleeding from the nasal cavity itself. The general site of bleeding or even the detailed site can be found, and electrocoagulation can be performed to stop the bleeding. It can also be combined with nasal tamponade. Our experience is to try to perform local micro-fillings with antibiotic gelatin sponges or to fill them with petroleum jelly gauze to reduce tissue damage and to reduce the chance of infection. If the nasal bleeding is so severe that it is difficult to aspirate it quickly with a suction device, we should compress the common carotid artery to reduce the bleeding, and at the same time, we should quickly determine whether the upper part of the nose (internal carotid artery system) or the lower part of the nose is bleeding under the nasal endoscope. The posterior nostril was caulked, so that the caulking could be released. The absence of intracranial infection in this group of bleeding cases may be related to the application of topical antibiotic gelatin sponges and the use of systemic high-grade antibiotics that can cross the blood-brain barrier in high doses, and possibly. It may also be related to the endoscopic localized release of the filling. Complex nasal skull base fractures are more common. In the clinical management of these patients, when the condition is stable, the main consideration is the recovery of nasal and facial shape and function. In the case of nasal bone/septum fractures, our experience is to perform a one-stage operation to repair the torn mucosa under nasal endoscopy, remove some of the dislocated cartilage and then retract it, while repositioning the nasal bone under direct vision. For orbital floor fractures, there are two main surgical approaches: the maxillary sinus approach and the infraorbital approach. Maxillary sinus approach: The traditional maxillary sinus approach is to open the maxillary sinus along the Ko-Lu incision and treat the fracture under direct vision with a common frontal mirror. However, because the fracture is usually located in the parietal wall of the maxillary sinus, the visual field is restricted to a certain extent, and the frontal mirror does not have enough reflective illumination, which makes the operation extremely difficult. In recent years, the use of sinus endoscopic minimally invasive surgery to treat orbital floor fractures has been reported at home and abroad with satisfactory results [. Ikeda et al. [reported the experience of 11 cases of intranasal repair of orbital floor burst fractures via nasal endoscopy, in which the natural opening of the maxillary sinus was fully enlarged to expose the orbital floor, and the orbital floor burst fractures were repaired via this approach, which was considered to have the advantages of clear visualization, less bleeding, and precise efficacy. The orbital floor burst fracture can be treated via sinus endoscopy either through the traditional Ko-Lu approach or through the middle nasal tract by enlarging the natural opening of the maxillary sinus to access the maxillary sinus. The application of different angles of the endoscope can clearly show the situation of each wall of the maxillary sinus, especially can clearly distinguish the orbital contents caught in the orbit, and can accurately identify the orbital rectus muscle caught in the maxillary sinus, which makes the precision of the operation greatly improved, and at the same time can significantly reduce the surgical trauma, in line with the characteristics of minimally invasive surgery. During surgery, the parietal wall of the maxillary sinus should be carefully examined, and the fracture fragment should be preserved as much as possible when it is attached to the mucosa, and the trapped extraocular muscle and other orbital contents should be loosened and retracted; in general, the orbital fat is mostly trapped, and special care should be taken not to damage the extraocular muscle so that the extraocular muscle can be completely retracted, and the trapped fat can not be retracted reluctantly; after the fracture fragment is retracted and healed and fixed, the trapped fat is not a big obstacle to eye movement. If the fracture area of the orbital floor is extensive and the fracture fragment is still inadequate, the fracture can be filled with autologous nasal septum bone fragments, which can be passed through the maxillary sinus cavity, preferably through the infraorbital route for easier treatment. In cases of combined frontal sinus, maxillary sinus, and septal sinus fractures, the main concern is the restoration of the shape and nasal ventilation function. It is easy to clean the nasal cavity endoscopically, carefully clean the old bleeding, remove the broken bone fragments of the fracture, open the septal sinus, enlarge the maxillary sinus opening, aspirate the blood accumulated in the maxillary sinus cavity, remove the frontal crypt, open the frontal sinus opening, and ensure the ventilation and drainage of each sinus cavity and the nasal cavity is the prevention and control of the corresponding sinus infection and even the formation of osteomyelitis The key. In the presence of an orbital cardboard fracture with herniation of the orbital fat, the orbital fat is repositioned and some of the necrotic fat should be cut away. We remove the lateral mucosa of the middle turbinate, fracture the middle turbinate laterally and try to displace it laterally and fill the septal sinus thus reinforcing the orbital fat plate. Most patients with combined anterior skull base fractures with cerebrospinal fluid rhinorrhea can be cured by conservative treatment. If the fracture persists after more than 2 weeks of conservative treatment, surgical repair is required. In recent years, nasal endoscopic transnasal repair of such patients has achieved satisfactory results, with the advantages of less trauma and higher cure rate compared to open repair. We have learned that for those whose leaks are at the top of the septal sinus, in order to improve the success rate of one-time surgery, the septal sinus should be fully opened, the leaks should be fully exposed, and the mucosa in the septal sinus should be removed as cleanly as possible. We used temporal fascia folded over the leak, which should be wide enough to exceed the leak by at least 1 cm and fixed with biologic adhesive, and then filled with fat, while removing the lateral mucosa of the middle turbinate, displacing the middle turbinate to the lateral fracture and compressing it and fully eliminating the septal sinus cavity. The medial aspect of the middle turbinate was filled with oil gauze, so that the leak was tightly blocked, and postoperative treatment continued according to conventional conservative treatment methods. For the combined septal fracture displacement, the septal cartilage is often dislocated and the septal mucosa is torn, so the cartilage should be reset as much as possible during the operation, and the part of cartilage that cannot be reset should be cut off, making sure that there is mucosa covering the cartilage, and the torn mucosa can be sutured as much as possible or fixed with bioprotein glue. In our group, two cases of displaced septal cartilage both had mucosal tears, and they were treated under nasal endoscopy according to the above mentioned methods with satisfactory results. The practice shows that the treatment of compound nasal skull base trauma injury by nasal endoscopy has the advantages of good exposure, simple and minimally invasive method, and real effect, which is worth further clinical exploration.