Surgical correction of Crouzon syndrome

This study analyzes the results of surgical treatment in 39 patients with the Crouzon syndrome. Early fronto-orbital advancement and craniectomy were universally successful in relieving raised intracranial pressure and in reducing ocular proptosis. However, definitive cosmetic correction was not achieved, and early cranial surgery was not able to prevent the development of midface hypoplasia. Thirty-two midfacial advancements have been performed in 30 patients. Sixteen patients had sufficient follow-up data for more than 2 years postoperatively. In all patients, a satisfactory early postoperative result was achieved. In the long-term follow-up group, 11 patients have maintained a satisfactory appearance, while 5 have developed recurrent deformity. Analysis shows this to be associated with a younger age at operation and continued mandibular growth. Frontofacial advancement in adults achieves good long-term results but is associated with a higher incidence of complications.

Oblique craniofacial fractures in children

The protected childhood environment and the anatomy of the craniofacial skeleton largely protect children from experiencing facial fractures. However, when major trauma to the head and face is sustained, an oblique pattern of fractures has been observed, distinct from those common in adults and explicable in terms of the anatomic differences between the child's and the adult's head and face. This difference in pattern of facial fracturing is relevant in terms of the examination, investigation and treatment of the primary injury, and prevention of any subsequent facial growth disturbances.

Cephaloceles: classification, pathology, and management

A cephalocele is defined as a herniation of cranial contents through a defect in the skull. Cephaloceles are classified according to their contents and location. We have reviewed a total of 112 patients with cephaloceles, 51 of whom had sincipital meningoencephaloceles (fronto-ethmoidal meningoencephaloceles). This group is distinctive in its demographic distribution, in the effect on growth of other facial structures, and in the combined craniofacial approach needed to treat them. This review is based on the sincipital encephaloceles with the other cephaloceles included for completeness. Despite many theories, the cause of congenital cephalocele is not known. Preoperative work-up includes 3-dimensional computed tomography scan of the facial skeleton, and surgical management is multidisciplinary in nature. The aim is to remove the lesion before the deformity has time to greatly distort facial growth, which appears to realign itself after surgery. The 50 patients who underwent surgery for fronto-ethmoidal encephalocele all survived with minimal complications.

Tessier clefts revisited with a third dimension

The classification by Tessier of rare craniofacial clefts brought, for the surgeon, order to a previously confusing array of anatomic and developmental descriptions. An ordered two-dimensional categorization of severe clefting malformations evolved from his clinical, radiologic, and surgical observations. The purpose of this paper is to report a complete series of facial clefts studied with computed tomography (CT) and three-dimensional reconstruction. The CT analysis supports some, but contradicts other, hypotheses and speculations presented by Tessier. The CT data reveal the scale of the reconstructive challenge and allow the assessment of our therapeutic interventions.

Hydrocephalus in Crouzon's syndrome

We reviewed 42 cases of Crouzon's syndrome. There were 16 cases with ventricular dilation. We believe that shunt should be inserted after fronto-orbital advancement if there are persistent signs of raised intracranial pressure. However, in cases presenting with severe ventricular dilation and papilloedema, a shunt is inserted prior to fronto-orbital advancement. Medium- or high-pressure systems should be used.

Cantilever nasal bone grafting with miniscrew fixation

A technique of rigid miniscrew fixation of cantilever nasal bone grafts is described. This produces stable, predictable nasal contour and tip projection without significant bone graft resorption.

The Tessier number 9 cleft

The clinical, radiologic, and operative examination of two patients with the Tessier number 9 cleft has allowed the first complete description of this, the rarest of the rare craniofacial clefts. Soft-tissue disruption extends from the lateral third of the upper eyelid through a distorted lateral end of the eyebrow to the temporal scalp, with an associated hairline indicator. The skeletal disturbance similarly radiates superolaterally from the superolateral orbital rim across the greater wing of the splenoid to the upper squamous temporal. The three-dimensional extent of the bony disruption is associated with distortion of the cranial base and calvaria above.

Computer-based coding of fractures in the craniofacial region

A systematic approach to the coding of fractures in the craniofacial region is presented. An alpha-numeric code is formulated from an alpha component depicting the anatomical region of interest and a number which reflects the degree of disruption.

Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.

Hairline indicators of craniofacial clefts

The review of a complete series of Tessier craniofacial cleft patients presenting to the South Australian Cranio-facial Unit has identified within the hairline a regular marker of clefting. Tongue-like projections of the temporal and frontal hairline pointing in the direction of their respective clefts have been identified for Tessier clefts numbered 7 to 14. No hairline indicator was revealed in "southbound" clefts numbered 0 to 6 without "northbound" extension. The hairline markers of laterally and superiorly bound clefts are a complementary element of the Tessier classification system.

Speech results of cleft palate surgery: two methods of assessment

After 10 years' work in the area of cleft palate, we decided to assess the acceptability of the speech of the children concerned. To ensure objectivity, untrained listeners, who were not aware that they were listening to children with repaired cleft palate, were asked to evaluate the child's spontaneous speech by comparing it with the speech of three of that child's peers. The results suggested that the child spoke less acceptably than his peers. As our aim was to compare the child with his peers, a rank ordering was selected as a means of evaluation rather than absolute judgements, i.e. a rating scale. The tape recordings of the cleft repaired children were also assessed by a speech pathologist experienced in the management of these children. The results of this assessment were comparable with results obtained overseas. In the light of our findings, we suggest that peer group comparison by untrained "naïve listeners may be a useful adjunct to the traditional assessment by the speech pathologist.

Technical aspects of the cranio-facial approach to tumours of the orbit and skull base

During the period July 1980-August 1987, 21 patients required cranio-facial extension of conventional neurosurgical osteotomies for tumours of the skull base and orbit. Five different types of combined osteotomies are described. Their applications to the treatment of various tumours and the subsequent reconstructions are presented and discussed.

Helmet-induced skull base fracture in a motorcyclist

Observations after a fatal motorcycle accident suggested that the face bar of a full-face helmet may transmit an impacting force to the skull base via the chin strap and the mandibular rami and condyles, bypassing the energy-absorbing facial bones. If this mechanism is confirmed, the structural properties of these face bars will need to be reassessed.

Hemifacial microsomia: a multisystem classification

Variability of deformities in hemifacial microsomia has precluded the general acceptance of any classification based on one reference organ. We present a review of hemifacial microsomia classifications and propose a TNM-style multisystem classification. This alphanumeric coding system, SAT, provides cohesion to existing hemifacial microsomia classifications. The acronym SAT is derived as follows: S = skeletal, A = auricle, and T = soft tissue. There are five levels of skeletal deformity (S1 through S5), four levels of auricular deformity (A0 through A3), and three levels of soft-tissue deformity (T1 through T3). Hence a patient with minimal deformity would be classified S1A0T1, whereas a patient with the most severe deformity would be S5A3T3.

Craniofacial infection in 10 years of transcranial surgery

Infection following transcranial surgery may be devastating. A review of 170 transcranial operations is presented with a focus on postoperative infection and its relationship to patient age, preoperative microbiology, pattern of operation, length of operation, and the use of antibiotic prophylaxis. The overall postoperative infection rate was 6.5 percent, but the infection rate in adults (23.5 percent) was much higher than in children (2.2 percent). Higher infection rates were found in adults with craniofacial dysostoses undergoing lengthy frontofacial advancements which required tracheostomy airway management. The residual frontal extradural dead space following advancement in adults is a sanctuary to infecting organisms from the respiratory tract--especially Pseudomonas transferred from the tracheostomy site into the upper airway and intracranial dead space by ventilation forces. Operating times for patients who became infected were 2 1/2 hours longer than average operating times for transcranial operations. Preoperative microbiology of the craniofacial region was not a good predictor of subsequent infection. Recommendations include operative intervention at an early age, short preoperative hospital stay, antibiotic prophylaxis to include gram-negative cover, surgical measures to either fill or isolate the dead space, and strict tracheostomy care--preferably with the patient being barrier-nursed.

Frontoethmoidal meningoencephaloceles

Frontoethmoidal meningoencephaloceles constitute a well-defined clinical entity with remarkable epidemiologic peculiarities, being very prevalent in Southeast and Southern Asia, but relatively rare in Western Europe, Japan, Australia, and North America. They do not show an increased risk of recurrence in siblings and offspring, unlike other cephaloceles and neural tube defects generally, from which they should be distinguished. Combined craniofacial and neurosurgical operative treatment permits one-stage correction of the whole deformity, the associated hypertelorism being reduced by selective orbital translocation and the nasal deformity by rhinoplasty. In planning these procedures, three-dimensional CT scanning is very helpful. Although our experience is chiefly with cases referred in childhood, we have some experience with operations done in infancy and believe this to be the ideal age.

Long-term effects of incorporated lime and topdressed lime on the pH in the surface and subsurface of pasture soils

Soil profiles from limed and unlimed commercial pastures and from lime trials on pastures in the Crookwell district of the Southern Tablelands of New South Wales were sampled and pH measured at 2- or 5-cm intervals to depths ranging from 10 to 60 cm. A single application of lime (3.6-5.6 t/ha depending on the soil) incorporated into the surface 10 cm had a long-term effect and maintained pH above 5.5 in the top 30 cm for at least 12 years. Lime applied as a topdressing to soils on granite raised the pH by at least 0.2 pH units to a depth of 15 cm after 6 years. The depth affected was less on the heavier-textured basaltic soils and on the initially more acid sedimentary soils. There appears to be a role for top-dressing with lime to prevent subsurface acidity from developing under pastures and to correct it in the upper layers of light textured soils. The pH profiles from a given treatment were variable and highlighted the problem of obtaining a field measurement for soil pH that is representative of the plant's environment.

Genetic variability for manganese concentration in Phalaris aquatica growing in acid soil

High levels of manganese in forage can retard the growth of livestock. The feasibility of breeding for lower manganese concentration in shoots of phalaris was examined in a variable population growing in acid, manganiferous soil. Sampling leaves of a particular physiological age in a field-growing breeding population provided an adequate indicator of manganese concentrations in whole shoots. Significant family differences were demonstrated. When transferred to sand culture, high manganese selections maintained consistently higher tissue manganese concentrations than low manganese selections over a wide range of manganese treatments. However, the range of variation was much smaller than in the field. Inheritance of manganese concentration was studied in 52 field-grown half-sib families and their parents from the breeding population. Mean family leaf sample concentrations ranged from 179 to 331 8g Mn g-1. Narrow-sense heritability estimates were 0.72 from the half-sib analysis and 0.40 from the parent-offspring relation. The former estimate is considered the more accurate, because the parent-offspring estimate was depressed by high random variation in some parent means. The mean manganese concentration of the population is predicted to decrease by approximately 80 8g g-1 in each generation in which progeny are raised only from those 25% of plants with the lowest manganese concentration. Although this estimate may have been influenced by available soil aluminium, it indicates that breeding for lower manganese concentration in phalaris is feasible.

Fever without a focus

Bacteremia occurs in 3 to 4 percent of ambulatory young children with fever. Bacteremic children may not appear seriously ill or have an identifiable source of infection, but they are at risk of developing septic complications if they are not treated appropriately. The physician must be aware of clinical criteria that identify children at increased risk for unsuspected bacteremia. Careful management leads to a relatively safe and successful outcome.

Skeletal morphology of anterior encephaloceles defined through the use of three-dimensional reconstruction of computed tomography

We have used three-dimensional reconstruction of computed tomography to study the morphology of anterior encephaloceles. The findings based on living patients rather than cadaver specimens confirm previous findings suggesting 'blow out' defects which displace otherwise normal osseous structures.