Helical CT and three-dimensional CT of facial and orbital injury

The Deviated Nasal Tip: A Personal Technique for Correction Using Monolateral Crural Overlay and Monolateral Dome Truncation

This study aimed to present a novel approach to correct nasal tip deviation with monolateral crural overlay or monolateral dome truncation, presenting as an isolated deformity or in complex nose deviations. Nasal tip deviation can be congenital or posttraumatic, due to a dislocated septum or cartilaginous septal or lower lateral cartilage malformations. Although some treatment strategies have been introduced, appropriate treatment remains a challenge because of the complexity and variability of such deformities. It had been assumed that in most nasal tip deviations, a lower lateral cartilage was longer than the contralateral one. The authors analyzed 158 patients from January 2015 to October 2019 with nasal tip deviation and corrected the deviated tip by using a monolateral interruptive technique (lateral crural overlay or monolateral dome truncation) on the lower lateral cartilage. Photographic comparison between preoperative and at least 1-year follow-up for nasal axis deviation variable was analyzed and a self-assessment questionnaire was administrated to the patients at 1-year follow-up. The mean nasal deviation was 6.59° (±3.1°) preoperatively and 1.56° (±0.26°) postoperatively (p < 0.05). The range of differences between pre and postoperative deviations was 2.7° to 15.1°, and the mean difference was 6.1° (±3.21°). Of the 84 patients, 47 (55.95%) were very satisfied, 33 (39.28%) were satisfied, and 4 (4.76%) were unsatisfied with surgical the results and required revision surgery. In authors' hands, monolateral interruptive techniques (lateral crural overlay or monolateral dome truncation) are a viable and feasible option to restore nasal tip symmetry. These techniques achieved high satisfaction rates among patients and resulted in reliable and reproducible symmetry immediately visible after surgery and stable over time (1-year postsurgery controls).

Computed tomography estimation of the prevalence of neuro-ophthalmic injuries in head trauma patients seen in a tertiary health facility in Ghana

INTRODUCTION

Prevalence of traumatic brain injury (TBI) is extremely high and potentially associated with severe incapacitating consequences. Literature reports that 90% of road traffic deaths and injuries including TBI occur in low and middle-income countries including Ghana. Computed Tomography (CT) scan is the imaging modality of choice for the initial assessment of the extent of head injury. Some Neuro-ophthalmic injuries (NOI) may sometimes be ambiguous and indistinct although a serious injury with potential damaging consequences. Data on the prevalence of NOI post trauma is non-existent in Ghana to inform policy. The onus therefore lies on the Radiologist who will review the head CT scan to be very meticulous not to miss any NOI if present. We therefore decided to diligently review a large cross-sectional retrospective post trauma head CT scans for occurrence of NOI.

OBJECTIVE

To determine the incidence of NOI secondary to head trauma and the possible loss of vision thereof in a retrospective study using patients' head CT scan data from a tertiary hospital's CT centre in Cape Coast, Ghana.

METHOD

All head CT scans secondary to trauma for the period January 2016 to December 2018, were retrieved and carefully analysed. A total number of 1043 of head CT scan images were analyzed by Consultant Radiologists.

RESULTS

Results showed out of 1043 CT scans reviewed, 742 (71,1%) were males and 301 (28.9%) were females. A total of 609 (58.4%) out of the 1043 patients sustained NOIs of various anatomical types. More Males 398 (65.4%) sustained NOI than females 211 (34.6%). The incidence of NOI was more among the youth as majority 167 (27.4%) of the patients were within the 18-29 years followed by 30-39 years bracket of 148 (24.3%). Fourteen anatomical types of NOI were elicited and further analysis revealed, intra-ocular foreign body to be the highest 107 (17.6%) cases, orbital floor fractures injury was 92 (15.1%) cases, with globe rupture injury and intraocular hemorrhage recording 79 (13.0%) cases each. Optic nerve injury was the least revealing 7 (1.1%) cases. There was a relationship between the gender of patient and the propensity to sustain NOI as males were more disposed to NOI than females. Road traffic accident (RTA) was the main pervasive cause of TBI and this accounted for 71.9% of all cases, followed by fall from height 24%, and the least cause of TBI was ascribed to gunshot injury of 0.33%.

CONCLUSION

Prevalence of NOI is high. Urgent measures must therefore be implemented to reduce the RTA menace in general and to mitigate the associated NOI and possible loss of vision thereof.

Dynamic changes of facial skeletal fractures with time

To investigate the characteristics of imaging changes with time of facial fractures, patients with facial fractures who had computed tomographic scan were enrolled including 500 patients who were divided into six groups based on the time of scanning: super early (<3 d), early (4–7 d), early-to-medium (8–14 d), medium (15–21d), medium-to-late (22d–2 months) and late stage (>2 months). The data were compared and analyzed. Forty two patients with frontal bone fractures had high-energy impact as the reason of fractures. The fracture line was clear and sharp within one week but blunt and sclerotic due to bone absorption at 2–3 weeks, and might exist for a long time. All patients had soft tissue swelling and paranasal sinus effusion at 1–2 weeks after injury. Air might gather in the adjacent soft tissues and/or intracranially within 3 days of injury if the fracture involved the frontal or other sinuses. Twelve of the 42 patients (28.6%) had intracranial hematoma, and five (11.9%) had epidural effusion. Subarachnoid hemorrhage was mostly absorbed within one week while epidural hematoma was completely absorbed over 3 weeks. Significant changes (P < 0.05) in the fracture lines, effusion of paranasal sinuses, soft tissue swelling and pneumocephalus were observed during the study period. For patients with medial orbital wall fractures, the fracture line was sharp and clear at early stages with concurrent sphenoid sinus effusion, and the fracture line became depressed 3 weeks later with disappearance of sphenoid sinus effusion. Significant changes (P < 0.05) were observed in the sharp fracture line, soft tissue swelling, sphenoid sinus effusion and smooth depression at fracture sites. For nasal fractures, the fracture line was sharp and clear at early stages with concurrent soft tissue swelling which disappeared one week later. The fracture line became smooth three weeks later. A significant (P < 0.05) difference was demonstrated in the changes of fracture line and soft tissue swelling with time. In conclusion, facial fractures have some dynamic alterations with time and identification of these characteristics may help reaching a correct clinical diagnosis with regard to fracture severity and time.

A comparable study of the diagnostic performance of orbital ultrasonography and CBCT in patients with suspected orbital floor fractures

OBJECTIVES:

To compare the diagnostic performance of ultrasonography and CBCT against CT in detecting orbital floor fractures.

METHODS:

A total of 120 orbits with clinical suspicion of isolated orbital floor fractures underwent multislice CT scanning with coronal reconstruction; orbital ultrasonography using a standard machine equipped with a 7- to 10-MHz linear transducer; and CBCT. Patients with severe head and face injuries were not included. The diagnostic performance of ultrasonography and CBCT was reported assuming conventional CT as the imaging method of choice.

RESULTS:

According to CT findings, fractures of the floor were present in 39 orbits. The sensitivity, specificity, positive-predictive value and negative-predictive value of ultrasonography in detecting orbital floor fractures were 87.2%, 100%, 100% and 94.2%, respectively. The corresponding values for CBCT were 97.4%, 97.5%, 95.0%, and 98.8%, respectively. Areas under the receiver operator characteristics curves of orbital floor fracture detection were 0.94 for ultrasonography and 0.98 for CBCT.

CONCLUSIONS:

When conventional CT cannot be performed in patients with clinically suspected orbital floor fracture and no severe or complex head and face injuries, CBCT could be used in detecting fractures as a reliable surrogate. Because of a lower sensitivity of ultrasonography, however, its use is limited in this regard.

Facial pillars in dogs: an anatomical study

This study describes the facial pillar system in dolichocephalic and brachycephalic breeds of dogs, and highlights its differences. Knowledge of facial pillar system anatomy is imperative to carry out successful fracture repair. The aim of our study was to describe the pillar system of the facial skeleton in dogs, and compare different shapes of dog skulls using native skulls, radiographs and computed tomography (CT). The heads of brachycephalic and dolichocephalic dogs were investigated following a maceration process using trans-illumination, radiography and CT. Ground sections were created from bones of the facial skeleton for investigation of osteon directions. This study has revealed that the facial skeleton of the dog has numerous sinuses supported by vertically and horizontally oriented bone pillars. These pillars can be divided into five principal regions in dolichocephalic skulls and six principal regions in brachycephalic skulls. Radiographic imaging of both the brachiocephalic and dolichocephalic skulls was not capable of discerning bone pillars. Computed tomography transverse and horizontal section images discerned all pillars observed in the illuminated skulls.

Facial Fracture in the Setting of Whole-Body CT for Trauma: Incidence and Clinical Predictors

OBJECTIVE

The objective of our study was to identify the incidence and clinical predictors of facial fracture in the setting of whole-body MDCT for trauma.

MATERIALS AND METHODS

The clinical data from the electronic medical records, including the final radiology reports, of 486 consecutive patients who underwent MDCT for trauma (head, cervical spine, chest, abdomen, and pelvis examinations) with dedicated maxillofacial reconstructions from October 1, 2011, to July 31, 2013, were studied. The clinical variables were compared between cohorts of patients with and those without facial fracture. The two-sample t test was used to compare continuous variables, and the Fisher exact test was used to compare categoric variables.

RESULTS

Two hundred sixteen (44.4%) patients had at least one fracture on the dedicated maxillofacial CT examinations, 215 of whom had facial physical examination findings (sensitivity = 99.5%). Of the 28 patients without documented physical examination findings, 27 did not have a facial fracture (negative predictive value = 96.4%). Statistically significant differences were found between positive and negative cases of facial fracture in patients with a Glasgow coma scale (GCS) score of 8 or less (p < 0.0001), an injury severity score of 16 or greater (p < 0.0001), acute alcohol intoxication according to blood alcohol concentration (BAC) (p = 0.0387), intubation at presentation (p < 0.0001), positive physical examination findings (p < 0.0001), and loss of consciousness (p = 0.0364). Falls from a height greater than standing height and open-vehicle collisions had the highest fracture rates (80.0% and 58.3%, respectively).

CONCLUSION

A negative finding at facial physical examination reliably excluded fracture. Clinical variables positively associated with facial fracture included the following: GCS score of 8 or less, ISS of 16 or greater, alcohol intoxication according to BAC, intubation at presentation, loss of consciousness, and the presence of abnormal facial findings at physical examination.

The Comprehensive AOCMF Classification System: Radiological Issues and Systematic Approach

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial (CMF) classification system with increasing level of complexity and details. The basic level 1 system differentiates fracture location in the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94); the levels 2 and 3 focus on defining fracture location and morphology within more detailed regions and subregions. Correct imaging acquisition, systematic analysis, and interpretation according to the anatomic and surgical relevant structures in the CMF regions are essential for an accurate, reproducible, and comprehensive diagnosis of CMF fractures using that system. Basic principles for radiographic diagnosis are based on conventional plain films, multidetector computed tomography, and magnetic resonance imaging. In this tutorial, the radiological issues according to each level of the classification are described.

Emergency radiology: Maxillofacial and skull-base trauma

Craniofacial trauma is common following road-traffic accidents, assaults and falls and may occur in isolation or associated with other body injuries. Due to the complexity of the maxillofacial and skull-base region, initial diagnosis may be inaccurate or delayed, leading to significant morbidity. Multidetector computed tomography is the modality of choice following high-energy blunt or penetrating trauma. It allows accurate evaluation of the fracture patterns and associated soft tissue complications and aids the appropriate medical and surgical treatment. In this article, we review and classify the most common traumatic injuries to the maxillofacial and skull-base region and outline the role of imaging in establishing complications and prognosis.

Mandibular fracture patterns consistent with posterior maxillary fractures involving the posterior maxillary sinus, pterygoid plate or both: CT characteristics

OBJECTIVES

The aim of this study was to determine the incidence of posterior maxillary fractures involving the posterior maxillary sinus wall, pterygoid plate or both, unrelated to major midface fractures in patients with mandibular fractures, and to characterize associated fractures.

METHODS

A CT study was performed in patients with mandibular fractures to identify posterior maxillary fractures. Patients aged under 16 years, those with mandibular fractures involving only dentoalveolar components and those with concurrent major midfacial fractures were excluded.

RESULTS

13 (6.7%) of 194 patients with mandibular fractures also had posterior maxillary fractures (case group). The injury pattern correlated with the external force directed to the lateral side of the mandible (p < 0.001), alcohol consumption (p = 0.049), the presence of multifocal fractures (p = 0.002) and the fracture regions in the symphysis/parasymphysis (p = 0.001) and the angle/ramus (p = 0.001). No significant difference between the case and non-case groups was seen for age, sex or cause of trauma. Non-displaced fractures in the ipsilateral posterior mandible occurred with significant frequency (p = 0.001) when the posterior maxillary fractures involved only the sinus.

CONCLUSIONS

Mandibular fractures accompanied by posterior maxillary fractures are not rare. The finding of a unilateral posterior maxillary fracture on CT may aid the efficient radiological examination of the mandible based on possible patterns of associated fractures, as follows: in the ipsilateral posterior region as a direct fracture when the impact is a medially directed force, and in the symphysis/parasymphysis or contralateral condylar neck as an indirect fracture.

Orbital fractures: role of imaging

The orbit may be injured directly or indirectly. Blunt and penetrating trauma occurs with equal frequency. Soft tissue swelling often obscures direct clinical evaluation of the globe, limits ocular motion, and may limit clinical assessment of vision. Plain film radiographs of the orbits and sinuses are rarely used for diagnosis in orbital trauma. Computed tomography is considered the imaging modality of choice in this circumstance, as it is deemed to be the most accurate method in detecting fractures. The protocol is based on obtaining thin-section axial scans and multiplanar reformatted images, both are useful tools to guide treatment. Orbital fractures are not considered an ophthalmologic emergency unless there is visual impairment or globe injury. Surgical repair is indicated for patients who have persistent diplopia or cosmetic concerns (enophthalmos) and generaly is not performed until swelling subsides 7-10 days after injury.

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

OBJECTIVE

To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.

DESIGN

Meta-analysis of randomised controlled trials.

POPULATION

Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations.

INTERVENTIONS

Antibiotic treatment versus appendicectomy.

OUTCOME MEASURES

The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.

RESULTS

Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I(2)=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I(2)=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

CONCLUSION

Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.

The role of three-dimensional CT in the evaluation of nasal structures and anomalies

Traditionally, computed tomography (CT) is the primary radiographic method to analyze the morphology of the craniofacial bones: Because of the many overlapping anatomical structures, it is difficult and sometimes impossible to evaluate craniofacial bones three-dimensionally (3D) with these images. For this reason, the aim of this paper has been to evaluate and demonstrate the importance of CT scans integrated by three-dimensional reconstructions (3D-CT) volume rendering imaging for the accurate understanding of the nasal pyramid morphology in the evaluation of patients submitted to secondary rhinoseptoplasty. Twenty patients enrolled for a secondary rhinoseptoplasty, underwent a preoperative evaluation through 3D-CT volume rendering imaging. This technique allowed a prefect reconstruction of the nasal structures at the level of the valve, as well as the medial and lateral walls of the nasal fossa in all of its components (bone and cartilage). In our experience, the 3D-CT volume rendering imaging studies improve the preoperative evaluation of structures and anomalies which are hard to evaluate by the anterior rhinoscopy and/or nasal endoscopy: alar and lateral cartilages, interdomal distance, tip morphology, valvular configuration, loss of bone-cartilaginous substance, etc. All of these points are important during the preoperative planning of secondary rhinoseptoplasty.

Multidetector and three-dimensional CT evaluation of the patient with maxillofacial injury

Interpretation of images associated with the traumatically injured face is challenging. The complexity of facial anatomy, coupled with the superimposition of numerous bony structures on plain radiographs, poses specific obstacles to accurate interpretation of facial injury. Although plain radiographs can be helpful in cases of isolated injuries, CT is the most useful modality for evaluating facial injury. This article reviews facial anatomy as it pertains to traumatic injury, emphasizes the clinical findings associated with various types of facial injury, and simplifies the diagnosis of facial injury on CT.

Critical computed tomographic diagnostic criteria for frontal sinus fractures

PURPOSE

Diagnosis and treatment of frontal sinus fractures (FSFs) have progressed over the previous 30 years. Despite advances in computed tomography, there is no current diagnostic uniformity with regard to classification and treatment. We developed a statistically valid treatment protocol for FSFs based on injury pattern, nasofrontal outflow tract (NFOT) injury, and complication(s). These data outlined predictable injury patterns based on specific computed tomographic findings critical to the diagnosis and ultimate treatment of this potentially fatal injury.

MATERIALS AND METHODS

A retrospective review was conducted on patients with FSF from 1979 to 2005 under institutional review board approval. All computed tomographic scans were reviewed by the authors and fractures categorized by location, displacement, comminution, and degree of NFOT injury.

RESULTS

One thousand ninety-seven patients with FSF were identified, 87 expired and 153 had inadequate data, leaving a group of 857 patients. Simultaneous displacement of anterior-posterior tables constituted the largest group (38.4%). NFOT injury occurred in most patients (70.7%) and was strongly associated with anterior (92%) and posterior (88%) table involvement (comminuted 98%). Sixty-seven percent of patients with NFOT injury had obstruction. Five hundred four patients (59.6%) had surgery with 10.4% complications and 353 patients were observed with 3.1% complications. All but 1 patient with complications had NFOT injury (98.5%).

CONCLUSIONS

Predictable patterns of injury based on specific computed tomographic data play a pivotal role in classification and surgical management of potentially fatal frontal sinus injuries. Radiologic diagnosis of NFOT injury in FSFs, particularly obstruction, plays a decisive role in surgical planning.

Computed tomography imaging strategies and perspectives in orbital fractures

Objective:

The objective of this study was to demonstrate the sensitivity and specificity of multislice computed tomography (CT) for diagnosis of orbital fractures following different protocols, using an independent workstation.

Materials and methods:

CT images of 36 patients with maxillofacial fractures (symptomatic to orbit region) who were submitted to multislice CT scanning were analyzed, retrospectively. The images were interpreted based on 5 protocols, using an independent workstation: 1) axial (original images); 2) multiplanar reconstruction (MPR); 3) 3D images; 4) association of axial/MPR/3D images and 5) coronal images. The evaluated anatomical sites were divided according to the orbital walls: lateral (with or without zygomatic frontal process fracture); medial; superior (roof) and inferior (anterior, medial). The collected data were analyzed statistically using a validity test (Youden's J index; p<0.05). The clinical and/or surgical findings (medical records) were considered as the gold standard to corroborate the diagnosis of the anatomical localization of the orbital fracture.

Results:

3D-CT scanning presented sensitivity of 78.9%, which was not superior to that of MPR (84.0%), axial/MPR/3D (90.5%) and coronal images (86.1%). On the other hand, the diagnostic value of axial images was considered limited for orbital fractures region, with sensitivity of 44.2%.

Conclusions:

Except for the axial images, which presented a low sensitivity, all methods evaluated in this study showed high specificity and sensitivity for the diagnosis of orbital fractures according to the proposed methodology. This protocol can add valuable information to the diagnosis of fractures using the association of axial/MPR/3D with multislice CT.

Imaging of orbital trauma

Assessing traumatic orbital injuries is an important challenge for radiologists; this assessment is even more difficult when the orbital injury is associated with injuries involving multiple organs. Common posttraumatic orbital injuries include anterior chamber injuries, injuries to the lens, open-globe injuries, ocular detachments, intraorbital foreign bodies, carotid cavernous fistula, and optic nerve injuries. Radiographic examination of the orbits is rarely performed. Ultrasonography (US) can be very useful for evaluating the globe and its contents; however, US is contraindicated if a ruptured globe is suspected. Magnetic resonance imaging may be difficult to perform emergently; it is contraindicated if there is a possibility that a metallic intraorbital foreign body is present. Computed tomography (CT) is considered to be the top choice for evaluating orbital trauma. The best protocol is to obtain thin-section axial CT scans, then to perform multiplanar reformation. When evaluating a patient with an orbital injury, the radiologist should do the following: (a) evaluate the bony orbit for fractures, note any herniations of orbital contents, and pay particular attention to the orbital apex; (b) evaluate the anterior chamber; (c) evaluate the position of the lens (the lens may be displaced, and it may be either completely or partially dislocated); (d) evaluate the posterior segment of the globe, look for bleeds or abnormal fluid collections, and evaluate for radiopaque or radiolucent foreign bodies; and (e) evaluate the ophthalmic veins and the optic nerve complex, especially the orbital apex.

Incidence and characterization of unifocal mandible fractures on CT

BACKGROUND AND PURPOSE

Conventional thinking among radiologists is that the mandible acts as a closed "ring" that needs to fracture at 2 points, though the frequency of multiple mandible fractures has been reported to be only as high as 67%. However, many of these studies did not use CT to confirm the presence of suggested fractures and excluded nondisplaced fractures. The purpose of this study was to determine the incidence of unifocal mandibular fractures on the basis of detection with dedicated facial bone CT scans and to characterize these fractures.

MATERIALS AND METHODS

We retrospectively reviewed the imaging reports of patients during a 3-year period to identify those who had mandible fractures documented on dedicated facial bone CT scans. The incidence of unifocal fractures was determined, the unifocal fractures were further subcategorized, and any derangements of the temporomandibular joints were also evaluated.

RESULTS

One hundred two patients met the inclusion criteria. The incidence of unifocal mandible fractures was 42% (43/102). Three unifocal fracture patterns identified were the following: simple fractures (25/42, 58%), comminuted fractures (11/42, 26%), and fractures associated with condylar subluxations (7/42, 16%). Most fractures had none to mild displacement or distraction.

CONCLUSION

Unifocal mandible fractures occur with greater frequency than anticipated by most radiologists. This may be due to the somewhat dynamic nature of the mandibular "ring," which includes the temporomandibular joints, though joint derangements evident on CT occur in the minority of cases.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

MDCT of the Elbow in Pediatric Patients with Posttraumatic Elbow Effusions

OBJECTIVE

The purpose of this study was to determine the performance characteristics of MDCT in the detection of fractures in children with posttraumatic elbow effusions and to assess the effect of MDCT findings on clinical management.

SUBJECTS AND METHODS

Unenhanced MDCT of the elbow was prospectively performed without sedation on 31 children 20 months to 16 years old who had posttraumatic elbow effusions. Two blinded reviewers independently and in consensus characterized all MDCT scans as positive or negative for the presence of fracture. Level of interobserver agreement was determined with the kappa statistic. Sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for fracture detection were determined for the consensus MDCT interpretations with follow-up radiographs as the reference standard. Patients were treated with casts and instructed to return in 2-3 weeks for clinical and radiographic follow-up unless a change in management was indicated on the basis of MDCT findings. The frequency of alteration of management was determined.

RESULTS

Both reviewers detected fractures in 15 (48%) of the patients individually and in 16 (52%) of the patients by consensus. Interobserver agreement for fracture detection with MDCT was excellent (kappa = 0.85). The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in the detection of fractures were 92%, 79%, 79%, and 92%, respectively. Four (13%) of the children had changes in management based on the MDCT findings.

CONCLUSION

MDCT is a sensitive means of evaluating for radiographically occult fractures in children with posttraumatic elbow effusions. It has a high negative predictive value and a high level of interobserver agreement. MDCT findings may lead to alteration of treatment of children with nondisplaced lateral condylar and radial head fractures.

[Orbital blow-out fractures]

Blow-out fractures, lateral fractures of the face, involve only the inferior and sometimes the medial wall of the orbit. Clinical diagnosis is not always obvious, and CT is helpful to confirm diagnosis and also detect some failures of surgical treatment: improper position or size of the graft. MRI is valuable to evaluate post-surgical infections.

16-MDCT of the Posttraumatic Pediatric Elbow: Optimum Parameters and Associated Radiation Dose

OBJECTIVE

Our objective was to investigate a low-radiation-dose protocol for 16-MDCT of the posttraumatic pediatric elbow using z-axis automatic tube-current modulation, based on optimum scanning parameters determined in a porcine fracture model, and to report the radiation dose from this technique in nine children with acute elbow trauma.

CONCLUSION

For the posttraumatic pediatric elbow, 16-MDCT using z-axis automatic tube-current modulation was optimal at 100 kVp with a noise index of 20 and a minimum amperage of 25 mA.

The Identification of Mandible Fractures by Helical Computed Tomography and Panorex Tomography

The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation of patients who have experienced trauma. However, panoramic tomography (PT) continued to be superior in sensitivity to CT in the identification of mandible fractures and has been considered the gold standard for the past 3 decades. In 1989, a faster, higher-resolution spiral or helical CT (HCT) became widely available, and its efficacy in multiplanar evaluation and diagnosis of fractures of the upper two thirds of the face has been well established. The sensitivity of this new-generation HCT in comparison to PT in the detection of mandible fractures has not been determined. The purpose of this study was to compare the sensitivity, physician interpretation error, and interphysician agreement of HCT and PT in the identification of mandible fractures. The number and anatomical location of mandible fractures identified by HCT and PT was not significantly different. However, the number and location of 96% of fractures identified by HCT was agreed on by neuroradiologists compared with only 91% of fractures identified by PT. Furthermore, the interphysician agreement when no fracture was identified was 96% by HCT versus only 81% by PT. In conclusion, HCT has enhanced imaging quality, equivalent sensitivity in identification of fractures, decreased interpretation error, and greater interphysician agreement in the identification of mandible fractures. HCT has surpassed PT as the current gold standard for the radiographic evaluation and diagnosis of mandible fractures.

[Intraorbital wooden foreign body, diagnosed by NMR and ultrasonography, and extirpation by cranio-orbital approach]

AIM

The case of the phlegmon of the left orbit associated with ophtalmoplegia and blindness in a 16-years old boy was presented. It was caused by the penetrafion of the wooden foreign body under unknown circumstances.

CASE REPORT

Repeated CT scans did not reveal the presence of the foreign body before MR imaging and ultrasonography. The removal (43 x 8 mm) was done one month after the injury by osteoplastic orbitotomy, using microsurgical technique. Three months later the signs of inflammation and eye protrusion withdrew. Motility of the left upper lid and eye were normal.

CONCLUSION

MR imaging and ultrasonography were decisive in the diagnose of organic foreign body in the orbit.

Radiologic assessment of maxillofacial, mandibular, and skull base trauma

Cranio-maxillofacial injuries affect a significant proportion of trauma patients either in isolation or concurring with other serious injuries. Contrary to maxillofacial injuries that result from a direct impact, central skull base and lateral skull base (petrous bone) fractures usually are caused by a lateral or sagittal directed force to the skull and therefore are indirect fractures. The traditional strong role of conventional images in patients with isolated trauma to the viscerocranium is decreasing. Spiral multislice CT is progressively replacing the panoramic radiograph, Waters view, and axial films for maxillofacial trauma, and is increasingly being performed in addition to conventional films to detail and classify trauma to the mandible as well. Imaging thus contributes to accurately categorizing mandibular fractures based on location, into alveolar, mandibular proper, and condylar fractures-the last are subdivided into intracapsular and extracapsular fractures. In the midface, CT facilitates attribution of trauma to the categories central, lateral, or combined centrolateral fractures. The last frequently encompass orbital trauma as well. CT is the imaging technique of choice to display the multiplicity of fragments, the degree of dislocation and rotation, or skull base involvement. Transsphenoid skull base fractures are classified into transverse and oblique types; lateral base (temporal bone) trauma is subdivided into longitudinal and transverse fractures. Supplementary MR examinations are required when a cranial nerve palsy occurs in order to recognize neural compression. Early and late complications of trauma related to the orbit, anterior cranial fossa, or lateral skull base due to infection, brain concussion, or herniation require CT to visualize the osseous prerequisites of complications, and MR to define the adjacent brain and soft tissue involvement.

Validity of multislice computerized tomography for diagnosis of maxillofacial fractures using an independent workstation

OBJECTIVE

The purpose of this study was to demonstrate the sensitivity and specificity of multislice computerized tomography (CT) for diagnosis of maxillofacial fractures following specific protocols using an independent workstation.

STUDY DESIGN

The study population consisted of 56 patients with maxillofacial fractures who were submitted to a multislice CT. The original data were transferred to an independent workstation using volumetric imaging software to generate axial images and simultaneous multiplanar (MPR) and 3-dimensional (3D-CT) volume rendering reconstructed images. The images were then processed and interpreted by 2 examiners using the following protocols independently of each other: axial, MPR/axial, 3D-CT images, and the association of axial/MPR/3D images. The clinical/surgical findings were considered the gold standard corroborating the diagnosis of the fractures and their anatomic localization. The statistical analysis was carried out using validity and chi-squared tests.

RESULTS

The association of axial/MPR/3D images indicated a higher sensitivity (range 95.8%) and specificity (range 99%) than the other methods regarding the analysis of all regions.

CONCLUSION

CT imaging demonstrated high specificity and sensitivity for maxillofacial fractures. The association of axial/MPR/3D-CT images added important information in relationship to other CT protocols.

Trends in the Use of CT and Radiography in the Evaluation of Facial Trauma, 1992–2002: Implications for Current Costs

OBJECTIVE

CT has replaced conventional radiography of the face in many trauma centers. Concern exists that increased costs are associated with increased use of CT. Our goal was to compare the amount of CT and radiography performed for facial trauma at a level 1 trauma center in 1992 and in 2002 and to determine hospital costs for the imaging of these patients.

MATERIALS AND METHODS

The changes in volume and types of facial imaging examinations were determined comparing 1992 and 2002. Hospital costs of different imaging examinations were determined for 2002. Current costs of imaging facial trauma were compared with what 2002 costs would have been if the practice pattern in 1992 had continued.

RESULTS

In 1992, 890 patients were evaluated for facial trauma. Six hundred seventy-one had only radiography, 153 only CT of the face, and 66 both CT and radiography. In 2002, 828 patients were evaluated. Five hundred eighty-four patients had only CT of the face; 228, only radiography; and 16, both CT and radiography. The number of facial imaging examinations per patient in 1992 and 2002 was 1.23 and 1.03, respectively. The 2002 hospital cost of a facial CT examination was $121 and of a facial radiography series was $154. Using CT instead of radiography for evaluating facial injury resulted in an overall cost savings of 22% per patient in 2002.

CONCLUSION

The availability of CT has not resulted in increased use of facial imaging. The increased use of CT from 1992 to 2002 results in decreased current costs for the hospital.

Do We Need Three-Dimensional Computed Tomography in Maxillofacial Surgery?

In a retrospective clinical study (2000-2003), 121 patients' radiographs and computed tomography scans were reviewed to establish the clinical value of three-dimensional computed tomography. Eighty patients had computed tomography scans; 48 had three-dimensional computed tomography scans for diagnosing facial fractures, 3 for diagnosing temporomandibular joint ankylosis, 1 for tumor with bone destruction, and 1 for a mandibular cyst. It is concluded that axial, coronal, and three-dimensional computed tomography is of crucial importance and should be mandatory for all suspected comminuted and displaced midface fractures instead of plain radiographs. Three-dimensional computed tomography is also recommended for comminuted mandibular fractures and temporomandibular joint ankylosis. Three-dimensional computed tomography is not recommended for the diagnosis of minimally displaced fractures.

Imaging of high-energy midfacial trauma: what the surgeon needs to know

Treatment goals in severe midfacial trauma are restoration of function and appearance. Restoration of function is directed at multiple organ systems, which support visual acuity, airway patency, mastication, lacrimation, smelling, tasting, hearing, and facial expression. Victims of blunt facial trauma expect to look the same after surgical treatment as before injury. Delicate soft tissues of the midface often make cosmetic reconstructive surgery technically challenging. Generally, clinical evaluation alone does not suffice to fully characterize facial fractures associated with extensive swelling, and the deeper midface is not accessible to physical examination. Properly performed computed tomography (CT) overcomes most limitations of presurgical examination. Thus, operative approaches and sequencing of surgical repair are guided by imaging information displayed by CT. Restoration of function and appearance relies on recreating normal maxillofacial skeletal anatomy, with particular attention to position of the malar eminences, mandibular condyles, vertical dimension and orbital morphology. Due to its pivotal role in surgical planning, CT scans obtained for the evaluation of severe midfacial trauma should be designed to easily depict the imaging information necessary for clinical decision making.

LEARNING OBJECTIVES

1. Understand the facial skeletal buttress system; 2. Understand how the pattern of derangement of the buttress system determines the need for and choice of operative approach for repair of fractures in the middle third of the face; 3. Understand the role and importance of CT and CT reformations in the detection and classification of the pattern of buttress system derangement.

Orbital apex injury: trauma at the junction between the face and the cranium

Orbital apex injury is usually seen in multiply and severely injured patients who are subject to high-energy trauma. Orbital apex injury rarely occurs in isolation. By proximity, the face, the skull base, or their combination are the most likely regions to be injured in association with orbital apex trauma. The vast majority of these injuries occur as an extension of orbital, LeFort, naso-orbito-ethmoid, panfacial, sphenoid, or temporal bone fractures of the skull. Complex osseous anatomic structures with intimately related multiple neurovascular organs make injuries to the orbital apex diagnostically and therapeutically challenging. Often other facial fractures extend into the orbital apex, or the orbital apex is damaged in conjunction with fractures of the skull base. Therefore abnormal imaging findings within the orbital apex may be indicators of traumatic injury to the entire junctional zone of face and cranium. In this article, we will give an overview of normal CT anatomy, review clinical syndromes, which may indicate traumatic injury of the orbital apex and present an imaging strategy for evaluation of the orbital apex.

Interpretation of mandibular condyle fractures using 2D- and 3D-computed tomography

Computed tomography (CT) has been increasingly used in the examination of patients with craniofacial trauma. This technique is useful in the examination of the temporomandibular joint and allows the diagnosis of fractures of the mandibular condyle. Aiming to verify whether the three-dimensional reconstructed images from CT (3D-CT) produce more effective visual information than the two-dimensional (2D-CT) ones, we evaluated 2D-CT and 3D-CT examinations of 18 patients with mandibular condyle fractures. We observed that 2D-CT and 3D-CT reconstructed images produced similar information for the diagnosis of fractures of the mandibular condyle, although the 3D-CT allowed a better visualization of the position and displacement of bone fragments, as well as the comminution of fractures. These results, together with the possibility of refining and manipulating perspectives in 3D images, reinforce the importance of its use in the surgical planning and evaluation of treatment. We concluded that 3D-CT presented supplementary information for a more effective diagnosis of mandibular condyle fractures.

A mild case of frontonasal dysplasia: the rhinologic perspective

Frontonasal dysplasia (FND) is a congenital malformation characterized by hypertelorism, broad nasion with a midline cleft in the bony dorsum, midline defect of the frontal bone, absence of the nasal tip, and deformities in the nasal alar region. The clinician should be aware of the mild forms of FND. We presented absence of crista galli in a mild case of FND. Computed tomography scanning should assess the facial bones, nose, and paranasal structures. If a surgical correction is planned, this complete work-up prevents unexpected complications and complements the evaluation of paranasal deformities.

Advances in imaging in oculoplastics

Color Doppler imaging, computed tomography (CT) and magnetic resonance (MR) imaging are the most precious imaging tools for the clinician in the field of oculoplastics. Orbital and facial vasculature, with its dynamic changes and flow velocities seen in orbital varices, carotid-cavernous fistulas, and dural cavernous arteriovenous malformations, is best detected by Color Doppler imaging. Computed tomography remains the dominant imaging modality in the evaluation of orbital trauma. Helical CT axial scanning with multiplanar reconstruction and three-dimensional CT imaging are most helpful in assessing iatrogenic, traumatogenic, and teratogenic orbital abnormalities. Despite its poor histologic specificity, MR imaging provides superior soft tissue contrast, and contrast-enhanced MR imaging has an established role regarding soft tissue tumor infiltration. The greatest value of MR studies in the evaluation of orbital and palpebral tumors is that it has the capacity to show the precise relation between lesions and adjacent structures before the clinician contemplates a surgical approach. Finally, contrast-enhanced MR imaging proved to be a valuable vascularization indicator based upon the extent of relative enhancement within porous orbital implant in anophthalmic socket.

Imaging of mandibular trauma: ROC analysis

OBJECTIVES

To compare the diagnostic efficacies of panoramic radiographs, mandibular trauma series, and digitized radiographs for detection of fractures of the mandible.

METHODS

Fractures were induced using blunt trauma in 25 cadaver mandibles. Panoramic radiographs, digitized radiographs, and mandibular series comprising an anteroposterior view, two lateral oblique, and a reverse Towne's were used. Six observers recorded their diagnoses using a five-point confidence rating scale. The data were analyzed using receiver operating characteristic (ROC) curve analysis.

RESULTS

Significant differences based on imaging modalities were found (p < 0.0015) in the area under the curves (A(z)): panoramic radiograph, 0.8762; mandibular series, 0.7521; panoramic plus anteroposterior radiographs combination, 0.8886; and digitized mandibular series, 0.7723. No observer-based differences were noted. Condylar and coronoid fractures were difficult to detect than those in other areas of the mandible (p < 0.033). Intra- and inter-observer agreements were high (kappa(w) = 0.81 and 0.76, respectively).

CONCLUSIONS

Panoramic radiographs are adequate for detection of mandibular fractures. Addition of an anteroposterior view augments diagnostic accuracy.