title: Transclival injury after routine transnasal rhinological surgery.
abstract: OBJECTIVE
  Routine transnasal rhinological procedures are widely practiced and are considered as safe, in general. Skull base lesions occur in less than 1% of procedures and typically involve the anterior or middle cranial fossa, while clivus lesions have not been well documented. Here we present a series of three patients with iatrogenic transclival lesions after routine transnasal rhinological procedures.
  
  
  METHODS
  Three patients with penetrating clivus injuries after routine transnasal rhinological procedures were identified. All patients had undergone transnasal rhinological surgery at other hospitals and two of them were referred for emergency treatment. Patients were managed within an interdisciplinary context.
  
  
  RESULTS
  There were two women and one man. Mean age at surgery was 35 years. All operations had been performed under general anaesthesia. In only one instance, perforation of the clivus had been noticed during surgery by the ENT physician, while it went unnoticed in the other two patients. In one patient, no intracranial injury occurred secondary to the clivus fracture, while two patients had extensive brainstem lesions. The first patient survived without deficits, but one patient succumbed to the brainstem injury and the other remained with severe deficits. Risk factors including anatomical variants or distorted morphology were present in all patients.
  
  
  CONCLUSIONS
  Transnasal rhinological procedures can result in penetrating clivus injuries, which may not be noticed during surgery, but which can result in permanent morbidity or mortality. These lesions are obviously very rare and their true incidence remains unknown.
authors.affiliation: Department of Neurosurgery, Medical School Hannover, Hannover, Germany. Electronic address: al-afif.shadi@mh-hannover.de.
authors.forename: Shadi
authors.initials: S
authors.lastname: Al-Afif
authors.affiliation: Department of Neurosurgery, Medical School Hannover, Hannover, Germany.
authors.forename: Makoto
authors.initials: M
authors.lastname: Nakamura
authors.affiliation: Department of Otorhinolaryngology, Medical School Hannover, Hannover, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Lenarz
authors.affiliation: Department of Neurosurgery, Medical School Hannover, Hannover, Germany.
authors.forename: Joachim K
authors.initials: JK
authors.lastname: Krauss
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003388:Cranial Fossa, Posterior / Q000293:injuries; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D008297:Male; D019291:Skull Base / Q000293:injuries*
keywords: Brainstem injury; Clivus fracture; Penetrating skull base injury; Transnasal approach