Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study

Traumatic Orbital Compression Syndromes: A Comprehensive Study Into Etiologies, Intervention Strategies, and Clinical Outcomes

Facial fractures and their historical link to potential blindness have been well-documented, often attributed to optic canal injuries or retinal vascular occlusion. This dire consequence can result from both direct and indirect ocular trauma, including retrobulbar hemorrhage. Traumatic orbital compression can manifest in various forms, such as hematomas, fractured bone fragments, and emphysema, all posing a significant threat to vision, necessitating immediate intervention. In this study, 9 clinical cases of traumatic orbital compression are presented, each characterized by distinct etiologies. The study delves into traumatic orbital compressive syndromes, underscoring the critical imperative of early recognition and treatment to prevent vision loss. Orbital compression, whether from edema, hematoma, or emphysema, collectively culminates in elevated intraorbital pressure and the potential for optic nerve ischemia. Through the presentation of these 9 clinical cases, the article emphasizes the pressing need for timely intervention in addressing orbital compressive syndromes to avert vision loss. Various surgical techniques are elucidated, highlighting the pivotal role of expeditious medical intervention. This article offers invaluable insights into the diagnosis, management, and outcomes of traumatic orbital compressive syndromes.

Clinical results of two different three-dimensional plate types for the treatment of mandibular angle fractures: a retrospective analysis

OBJECTIVES

The purpose of this study was to compare two different designs of three-dimensional osteosynthesis plates for their suitability in the treatment of mandibular angle fractures in terms of sufficient fracture healing and concomitant complications.

MATERIALS AND METHODS

Retrospectively a total of 54 patients with 56 mandibular angle fractures were evaluated. Two different types of three-dimensional plates from the Medartis Trilock system were analyzed: (A) Square design plate (☐-plate) with a thickness of 1.0 mm, and (B) triangular-shaped 3D-plate (△-plate) with a thickness of 1.3 mm. Patient demographics, fracture mechanism and intraoperative details were recorded during an average follow-up period of 1 year.

RESULTS

The utilization of △-plates was observed to entail a considerably lengthier surgical time in contrast to ☐-plate systems (P = 0.037). The application of △-plate showed a tendency of higher incidence of major complications than ☐-plate (P = 0.06), as evidenced by the occurrence of non-union in 2 out of 22 cases, resulting in higher surgical revision rate for △-plate (P = 0.027).

CONCLUSION

Sufficient treatment of mandibular angle fractures is feasible by using 1.0 mm thick, square shaped three-dimensional plate systems. The use of thicker three-dimensional osteosynthesis plates seems to significantly increase the operating time and complication rates, whereby the geometry of the plate seems to have an influence.

CLINICAL RELEVANCE

The plate design could have an impact on treatment outcomes of mandibular angle fractures.

TRIAL REGISTRATION NUMBER

Not applicable.

Systematic review of non-invasive ventilation and craniofacial fractures: a multidisciplinary perspective and recommendations for management

The anatomically complex craniofacial skeleton demands special consideration when caring for cases of polytrauma or medically compromised patients with craniofacial fractures. This paper utilises a systematic review and multidisciplinary opinions to create an algorithm for the hospital-based care of patients with craniofacial fractures (base of skull, orbit, paranasal sinus, and mandible) who require non-invasive ventilation (NIV). Each fracture location has a unique predisposition to a different type of emphysema and associated morbidity. The risk of developing emphysema, combined with its potential severity, is stratified against the harm of not providing NIV for the holistic care of the patient. The aim of this paper is to synthesise evidence from a systematic review of existing literature with multidisciplinary opinions to develop a concise algorithm that outlines the optimal treatment of patients with craniofacial fractures who require NIV.

A technical feasibility study on adaptation of a microsurgical robotic system to an intraoperative complication management in dental implantology: perforated Schneiderian membrane repair using Symani® Surgical System

The aim of the current study was to test the technical and clinical feasibility of a robotic system and investigate its potential in the surgical repair of perforated Schneiderian membranes using an ex-vivo porcine model. Eight pig heads were operated conventionally via a surgical loop and eight pig heads with the surgical robot "Symani® Surgical System" (Medical Microinstruments, Inc., Pisa, Italy). On each specimen, the Schneiderian membrane was incised over a length of 0.7 mm resembling a perforation. Operation time, the maximum sinusoidal pressure, the course of the pressure and the filling volume were measured. Additionally, adaptation of the wound edges has been detected via scanning electron microscopy. There were no significant differences for the pressure maximum (p = 0.528), for the time until the pressure maximum was reached (p = 0.528), or for the maximum filling volume (p = 0.674). The time needed for the suturing of the membrane via robotic surgery was significantly longer (p < 0.001). However, the scanning electron microscope revealed a better adaptation of the wound edges with robotic surgery. The technical feasibility of robot-assisted suturing of Schneiderian membrane laceration using the robotic system has been confirmed for the first time. No differences considering the pressure resistance compared to the conventional repair could be observed, but advantages in wound adaptation could be found with an electron microscope. Regarding the material and training costs and limited indications spectrum, robotic surgery systems still might not present financially feasible options in the daily dental practice yet.

An Elegant, Simple Solution to a Newly Described Phenomenon: Traumatic Nasomalar "Ball-valve" Fistula

Sequela of complex craniomaxillofacial trauma is common. We report a previously undocumented, highly unusual, postfacial trauma presentation of a "nasomalar ball-valve fistula." The clinical presentation was a sharp influx of air into the left malar subcutaneous space with each nasal inspiration, followed by near-complete deflation upon each expiration. We also report a very simple and elegant solution of using a nasal trumpet to completely resolve this problem without the need for additional operation. The final recovery was uneventful. We hope to make all facial surgeons aware of this diagnosis and to remind them to keep this simple device in their armamentarium to address similar issues.

Pneumomediastinum as a Complication of Oral and Maxillofacial Injuries: Report of 3 Cases and a 50-Year Systematic Review of Case Reports

Objectives

Pneumomediastinum (PM) secondary to oromaxillofacial trauma (OMF) is a rare but well-described complication/pathologic finding. The aim of this study was twofold: first, to report our experience in treatment of maxillofacial trauma patients with PM, and second, to review the literature regarding the clinical features, severity, course, and management of the aforementioned complication.

Material and methods

We retrospectively reviewed the medical records and charts of patients who suffered from maxillofacial trauma and treated in our hospital between September 1, 2013 and September 31, 2017. The inclusion criteria were patients with radiologically confirmed PM. In addition, the electronic databases PubMed, Scopus, and Science Direct were queried for articles reporting PM cases secondary to OMF injuries and published in English, French, and German language.

Results

Three cases of PM out of 3,514 cases of craniomaxillofacial trauma were found; there were 3 male patients who presented in our emergency department with the chief complaint of cervicofacial swelling. Literature search isolated 58 selected articles and 63 cases were assessed in total; posttraumatic repeated blowing of nose was proved as most frequent triggering factor among them. Furthermore, the outcomes of review showed that thoracic pain, respiratory distress, and swallowing difficulties were not frequently reported in patients with ME due to facial trauma.

Conclusions

Both our experience and the results of systematic literature review indicated that patients with PM due to OMF injuries present mild clinical course. If properly managed, this specific pathologic condition may have no further complications or relative comorbidities. The exact etiology and mechanism of PM in the context of maxillofacial injuries always needs to be identified. Radiographic, laboratory, and endoscopic examinations should be applied to rule out the more serious and frequently diagnosed aerodigestive, thoracic, and abdominal causes of PM.

Facial Emphysema following Closure of Oroantral Fistulae

Subcutaneous emphysema (SE) is a swelling which develops due to air entrapped underneath the subcutaneous tissue and facial planes causing distention of the overlying skin. SE can develop due to trauma, surgery, or infection. The diagnosis of SE is mostly based on clinical findings of crepitation upon palpation of the swelling. Once diagnosed, SE is usually managed by close observation and in some cases may require surgical decompression and antibiotic prophylaxis. We report a rare case of SE of the left malar which developed following closure of oroantral communication using the buccal fat pad.

Extensive Post-Traumatic Surgical Emphysema Exacerbated by Cocaine Insufflation

Surgical emphysema (SE) is characterized by air in the soft tissues causing a crackling sensation on palpation. In oral and maxillofacial surgery, it might occur using conventional air-driven dental hand pieces, as a complication of trauma and with cocaine insufflation.The subcutaneous air may travel through tissue planes causing cervicofacial emphysema, pneumothorax, and pneumomediastinum. It may carry bacteria and potentially lead to cellulitis or necrotizing fasciitis.The SE is usually a self-limiting entity requiring analgesia, close observation of the airway, occasionally prophylactic antibiotics, and rarely steroids. Although, the consensus on antibiotic and corticosteroid therapy is unclear.Here presented an unusual and extensive presentation of surgical emphysema. A 29 years old male presented with emphysema following a left orbital-zygomatic complex fracture and following intranasal cocaine insufflation. It extended from the temple to the parotid region, down into the neck and into the mediastinum. No surgical intervention was required. The patient was discharged after 24 hours of observation with a week-long course of co-amoxiclav antibiotics and no corticosteroids administration.Typical instructions following facial bone fractures are to avoid nose blowing because of the risk of SE, however, avoidance of drug habits is rarely considered. This case report highlights the importance of tailored advice to this particular patient cohort.

Orbital Emphysema After Repair of Orbital Fracture

Orbital emphysema is a rare postoperative complication that can cause diplopia and even visual loss. Therefore, immediate diagnosis and treatment are crucial. In this study, a healthy male patient sustained left facial trauma caused by a fall 2 months ago; orbit emphysema occurred when the patient sneezed on the 5th day after surgery. The patient was treated conservatively with oral antibiotics and oral dexamethasone. Sixth-month follow-up showed no residual lesion.

Massive Self-Induced Subcutaneous Cervicofacial, Pneumomediastinum, and Pneumopericardium Emphysema Sequelae to a Nondisplaced Maxillary Wall Fracture: A Case Report and Literature Review

Iatrogenic cervicofacial subcutaneous emphysema is a well-reported entity in the field of dentistry and oral and maxillofacial surgery, especially with the use of air-driven headpieces. Cervicofacial subcutaneous emphysema sequelae after maxillofacial trauma, however, has been reported less and the self-induced variant is even rarer. We report a case of massive cervicofacial subcutaneous emphysema, pneumomediastinum, and pneumopericardium in a healthy 16-year-old boy after blunt trauma to the face, which caused a nondisplaced anterior maxillary wall fracture. The findings from the present case report will validate the common phrase "no nose blowing or holding your sneezes" that clinicians tell patients after maxillofacial trauma and sinus surgery.

An Algorithm for the Management of Concomitant Maxillofacial, Laryngeal, and Cervical Spine Trauma

Concomitant maxillofacial, laryngeal and cervical spine injuries may occur after high-energy accidents. Although this presentation is uncommon, the multiple injuries may compromise airway, breathing, circulation, and neurologic function. We identified 8 adult trauma patients admitted to the National University Hospital with the concomitant injuries. We reviewed the patient data and existing literature to identify the important factors that must be considered for management. Seven resulted from high velocity accidents, whereas 1 was assaulted. An algorithm that prioritizes in-tandem diagnosis and acute management of the adult trauma patient with maxillofacial, laryngeal, and cervical spine trauma was developed. The first priority is to assess airway, breathing, and circulation with cervical spine immobilization. Early diagnosis of patients with severe laryngeal injury, confirmation by video endoscopy, and establishing a surgical airway prevents airway obstruction or even a laryngotracheal dissociation. Urgent computed tomography scans of the head and neck are essential for definitive diagnosis and surgical planning for the 3 injuries. Prudent sequencing of surgery is important to avoid complications and to achieve better functional outcomes.

Pneumatic dental extractions: an unusual cause of extensive cervical surgical emphysema

A 50-year-old fit and well man presented to the Accident and Emergency Department in a tertiary centre following lower molar extraction, complaining of voice hoarseness with neck and facial swelling. Clinical examination along with plain film radiography revealed pneumomediastinum and extensive cervical surgical emphysema. He was subsequently admitted for observation and managed conservatively under the ENT team with input from the maxillofacial and anaesthetic teams. With supportive treatment only, the emphysema resolved and he remained well up until discharge.

Subcutaneous emphysema after vigorous sneezing in the setting of acute frontal sinusitis

INTRODUCTION

Subcutaneous emphysema [SCE] can develop due to traumatic, infectious, and spontaneous causes and usually localizes to the periorbital space.

CASE

We present a case of an 18-year-old male with an 8-day history of migraine-like headaches followed by the acute onset of frontofacial swelling after vigorous sneezing. Radiologic and physical exam findings supported a diagnosis of frontofacial SCE in the setting of frontal sinusitis.

DISCUSSION

A sneeze, although usually benign, causes a significant increase in intranasal pressure. When coupled with a history significant for facial trauma or rhinosinusitis, this rise in pressure can be sufficient to cause fracturing of the bone overlying a paranasal sinus, leading to the formation of SCE.

Don't Blow It! Extensive Subcutaneous Emphysema of the Neck Caused by Isolated Facial Injuries: A Case Report and Review of the Literature

BACKGROUND

Although subcutaneous emphysema resulting from maxillofacial surgery is well described in the literature, the association with maxillofacial trauma is less firm. Clinically evident subcutaneous emphysema from facial injury is uncommon and extension into the cervical and mediastinal tissues is exceedingly rare, with few reported cases.

CASE REPORT

An unusual case of extensive subcutaneous emphysema after facial trauma is presented. The case posed a diagnostic dilemma in our emergency department. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Facial fractures are a rare but important cause of surgical emphysema. Emergency physicians need to be aware of the diagnostic possibility and the need to avoid factors that may precipitate secondary injury.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Facial emphysema after sinus lift

An 80-year-old man with a history of en bloc resection of squamous cell carcinoma of the hard palate (T4aN0M0) was performed a lateral-window sinus lift of the edentulous area of the left maxillary molar region to facilitate future placement of dental implants.

Two hours after the surgery, the patient complained of sudden malar swelling. Marked swelling was present from the left infraorbital region to the buccal region. The swelling was associated with air pockets at the alar base and in the angulus oculi medialis region and subcutaneous malar tissue. Emphysema appeared after the patient blew his nose. Therefore, the mucous membrane of the maxillary sinus might have had a small hole, and air might have entered the subcutaneous tissue via the bone window when the air pressure in the maxillary sinus increased with nose blowing. It is important to advise patients to avoid increasing the intraoral pressure after sinus-lift procedure.

A rare complication of rhinoplasty: periorbital emphysema

Subcutaneous emphysema is a clinical entity that may be associated with trauma. Rhinoplasty is not an atraumatic procedure. This report presents a case of acute periorbital emphysema after cosmetic rhinoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Posttraumatic orbital emphysema: incidence, topographic classification and possible pathophysiologic mechanisms. A retrospective study of 137 patients

OBJECTIVE

The aim of this study was to retrospectively evaluate the incidence of posttraumatic orbital emphysema (OE) and to propose a radiologic topographic classification as well as a possible pathophysiologic model.

STUDY DESIGN

Orbital fine-cut (1 mm) computerized tomographic scan slices from 137 patients were used to assess the fracture's type, the presence and position of OE, and periorbital tissue herniation. The OE was categorized into the following 5 compartments: subcutaneous periorbital, peribulbar, retrobulbar extra- and intraconal, and pterygopalatine fossa.

RESULTS

The incidence of OE was 61%. OE was more frequently associated with isolated medial wall (78%; P < .001) and combined medial wall/orbital floor (82%; P < .01) fractures. Palpable isolated subcutaneous eyelid emphysema was not related to fracture's type (P = .85).

CONCLUSIONS

OE suggested medial wall fractures alone or combined with orbital floor fractures. Pathophysiologically, according to the Poiseuille law, the difference in length between the ethmoid and sinusal infundibulii could explain the increased incidence of OE when the medial wall is involved.

Orbital emphysema following removal of bilateral midfacial implants

A 36-year-old man with Crouzon syndrome was referred post-operatively with unilateral painful limitation of eye movements and proptosis following removal of bilateral malar and orbital rim implants. Further investigation revealed right inferior orbital emphysema, caused by the intra-operative entrance of hydrogen peroxide through a suspected perforation of the orbital septum. The symptoms settled with conservative management.

Subcutaneous emphysema

Subcutaneous emphysema is a potential surgical complication arising due to introduction of air into the facial planes of the connective tissue. presence of air and accompanying inflammation and or infection could prove fatal in immediate post surgical scenario. This case report aims to prevent one such case of subcutaneous emphysema that was promptly diagnosis and effectively managed.

Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil

A retrospective study was performed to assess maxillofacial fractures in patients treated at a public hospital from 2002 to 2006. The data collected included age, gender, etiology, type of injury, treatment modalities and period of treatment. Causes were grouped into seven categories: road traffic collisions, sports accidents, occupational accidents, gunshot fractures, falls, violence and other causes. The analyses involved descriptive statistics, the Chi-squared Test and the Fisher Exact Test. Records from 132 patients sustaining 185 maxillofacial fractures were evaluated. The mandible (54.6%) was the most commonly fractured bone in the facial skeleton, followed by the zygoma (27.6%). The mean age of the patients was 37.7 years, and the male:female ratio was 4.3:1. Most fractures occurred in adults with ages ranging from 18 to 39 years. A significant statistical relation was found between the age and the etiology of the trauma (p < 0.05), and between the number of fractured sites and the age of the patient (p < 0.05). Considering the age groups, accidents were the most frequent cause of maxillofacial fractures in the age group between 18 to 39 years, and interpersonal violence was the most frequent cause of maxillofacial fractures in the age group between 40 to 59 years. Treatment was performed on the same day as the diagnosis in 44.7% of the patients. Open surgery with internal stable fixation was indicated for most of the patients. Facial fractures occurred primarily among men under 30 years of age, and the most common sites of fractures in the face were the mandible and the zygomatic complex. Traffic road collisions were the main etiologic factor associated with maxillofacial trauma.

Retropharyngeal and cervicofacial subcutaneous emphysema after maxillofacial trauma

INTRODUCTION

Subcutaneous emphysema in the cervical region is a well-documented event that may occur secondary to tonsillectomy, dental treatment, oropharyngeal barotraumas, scaling and root planning therapy, punch biopsy, endotracheal intubation, orthognathic surgery, extraction of impacted teeth, or after maxillofacial trauma. After trauma episodes, subcutaneous emphysema may be caused by a maxillary antral wall fracture that occurs when air pressure is introduced into the fascial planes of the connective tissue. Retropharyngeal emphysema is a severe condition associated with traumatic aerodigestive tract injury and may be associated with life-threatening situations requiring prompt attention and diagnosis in order to prevent serious consequences.

CASE REPORT

We reported a case of cervicofacial and retropharyngeal emphysema in a 54-year-old patient who stated concerns after blowing his nose several times after a traumatic episode involving orbitozygomatic region. During the patient's hospital course, his airway remained stable, and he was discharged from the hospital 7 days later with a prognosis of full recovery, excellent occlusion and facial appearance, and complete resolution of subcutaneous emphysema.

Frontal sinus pneumocoele: a rare cause of orbital emphysema

Sudden onset nonaxial proptosis and diplopia is alarming and orbital haemorrhage or a rapidly expanding orbital tumour should be excluded. We present a case of a young man aged 15 years who attended the Accident and Emergency Department with a 6-h history of sudden onset proptosis and diplopia in whom the aetiology was orbital emphysema.

Fever and Periorbital Edema: A Review

Fever and periorbital swelling are the manifestation of a broad array of diseases. Among them are emergency situations, which need prompt physician input. Swiftly formulating a differential diagnosis approach is crucial. Diseases causing fever and periorbital edema are either local or systemic. Nevertheless, their impact can be systemic if they evade diagnosis. Infectious diseases and non-infectious diseases (inflammatory and allergic diseases, autoimmune diseases, neoplastic diseases, and trauma) can all lead to fever and periorbital edema. A meticulous history and physical examination in association with targeted tests against the presented spectrum of diseases (specific serological tests, radiological tests, cultures taken from the surface of the periorbital area and other relevant areas, and skin biopsy for histological and microbiological examination) will clarify the diagnosis.

Delayed traumatic ocular emphysema: a case report

A 47-year-old man sustained fractures of the left orbita and zygomatic bone after a fall. He was advised to visit an oral and maxillofacial department for more detailed evaluation and treatment, but ignored the advice. Four days later, after sneezing and blowing his nose, he presented severe exophthalmos, diplopia, and reduction of vision. Two days after the symptoms presented he asked for oral and maxillofacial surgery consultation. He refused any surgical intervention and was treated conservatively. The recovery was slow and 1 week later he was discharged with slight esthetic problems.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.