When can patients blow their nose and fly after treatment for fractures of zygomatic complex: the need for a consensus

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.

Orbital Fractures and Air Travel

Previous surveys indicate that the majority of clinicians recommend avoidance of air travel for a period of time following an acute orbital fracture. This advice has largely been based on the theoretical risk that in-flight pressure variation may exacerbate orbital emphysema and produce visual compromise, though no previous reviews have been conducted on the evidence underpinning this advice. The purpose of this study was, therefore, to conduct a systematic review of the literature pertaining to the safety of air travel in the setting of an acute orbital fracture. A systematic review of the OVID Medline database - and of cases referenced as providing evidence for adverse outcomes due to flying with an orbital fracture - was carried out.Two articles were identified from the literature with data specific to patients who undertook air travel following orbital fractures. A large case series identified no complications in patients exposed to both pressurized and unpressurized air travel, and only a single case report detailed an adverse outcome requiring intervention. The remainder of the articles that had previously been cited as evidence against air travel involved additional factors such as intra-ocular pathologies. There is, therefore, a paucity of evidence to support the conventional advice regarding avoidance of air travel, though clinicians should exclude the possibility of an associated intra-ocular injury, advise against nose-blowing in flight, and provide advice regarding alternative methods to the Valsalva maneuver for equalizing middle ear pressure in flight.

LEVEL OF EVIDENCE

IV.

Water balloon-induced orbital fracture in an aviator

BACKGROUND

Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature.

CASE PRESENTATION

A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status.

CONCLUSIONS

Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Flying and midface fractures: the truth is out there

There are no clear, evidence-based guidelines that dictate when it is safe for a patient to fly after sustaining a midface fracture. From January 2006 to December 2009, the Royal Darwin Hospital Maxillofacial Unit had 48 out of 201 patients with an orbital fracture that involved a paranasal air sinus transported by a variety of aircraft to the unit for definitive management. No orbital complications were recorded for the 24% of patients requiring air travel to our tertiary referral centre. Furthermore, there were no recorded deviations from the standard flight plan. We believe that this demonstrates there are no absolute contraindications to flying on a variety of aircraft with a midface fracture, but clinical assessment remains crucial for an informed decision to transport these patients by air.

Pneumomediastinum secondary to isolated orbital floor fracture

Pneumomediastinum (PM) secondary to an isolated orbital blow-out fracture is a rare but potentially severe and life-threatening complication. Fortunately, airway obstruction, pneumothorax, pneumopericardium, and mediastinitis are rare complications of PM. Blowing the nose after a maxillofacial trauma increases pressure in the paranasal sinuses, which may lead to emphysema through a breach of the lining mucosa to the surrounding soft tissues in the head, neck, and, on occasions, to the mediastinum. We report here the rare case of a patient with PM after isolated orbital fracture. Only 3 similar cases have been previously reported in the literature.

Evaluation of treatment of zygomatic bone and zygomatic arch fractures: a retrospective study of 10 years

OBJECTIVE

The aim of this study was to investigate the treatment of zygomatic bone and zygomatic arch fractures without other facial fractures.

PATIENTS AND METHODS

A 10 year (2000-2010) retrospective study involving 310 patients admitted and treated for zygomatic bone and zygomatic arch fractures at the department of oral and maxillofacial surgery was done. The data collection protocol included: age, gender, site, type of fracture. Other data presented included clinical diagnosis, radiographic examination findings as well as preoperative and postoperative imaging for evaluation of the fracture. Descriptive statistics was performed with SPSS version 16.

RESULTS

The ages of the patients ranged from 10 to 76 years old, mean age was 32.33 years. 237(80.6%) of the patients were males and 73 (19.4%) were females (Table 1). According to the site of fracture, the patients were divided into three groups: group A, with zygomatic bone fracture, group B with zygomatic arch fracture and group C with co-existing zygomatic bone and zygomatic arch fracture. Regarding the site of fracture 57.7% of the patients had fractures of the zygomatic bone, 13.8% had fractures of the zygomatic arch and 28.4% had fractures of both zygomatic bone and zygomatic arch. [Table: see text] The treatment of both fractures was: closed reduction for isolated zygomatic arch fractures; open reduction and internal rigid fixation through a coronal incision was performed in comminuted arch fractures and displaced fractures.

CONCLUSION

In this study, the majority of the patients were young adult men; road traffic accidents were the leading cause of fractures. According to the site of fracture, various modalities of treatment were used and all the patients achieved satisfactory results without any complications after operation.

Orbital floor fracture and emphysema after nose blowing

INTRODUCTION

Orbital floor fractures are usually the result of mechanical trauma. Orbital emphysema tends to develop in fractures affecting the paranasal sinuses and walls of the orbit.

CLINICAL CASE

We report the case of a 35-year-old male who suffered an orbital floor fracture with associated orbital emphysema as a result of nose blowing.

DISCUSSION

Only one other similar case has been found in the literature.