Management of closed head injury in the patient with maxillofacial trauma

Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury

Aims and Objectives:

Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking.

Subjects and Methods:

We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically.

Results:

During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair.

Conclusions:

BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7–10 days has high risk of developing meningitis and likely to need surgical intervention.

Head Injury- A Maxillofacial Surgeon's Perspective

Injuries and violence are one of the leading causes of mortality worldwide. A substantial portion of these injuries involve the maxillofacial region. Among the concomitant injuries, injuries to the head and cervical spine are amongst those that demand due consideration on account of their life threatening behaviour. Studies have shown that facial fractures have a strong association with traumatic brain injury. Knowledge of the types and mechanisms of traumatic brain injury is crucial for their treatment. Many a times, facial fractures tend to distract our attention from more severe and often life threatening injuries. Early diagnosis of these intracranial haemorrhage leads to prompt treatment which is essential to improve the outcome of these patients. An oral and maxillofacial surgeon should be able to suspect and diagnose head injury and also provide adequate initial management.

A 7-year study of 1,278 patients with maxillofacial trauma and cerebrospinal fluid leak

BACKGROUND

A number of patients with facial fractures have cerebrospinal fluid (CSF) leak that may result in meningitis and other central nervous system complications. Commonly, CSF leak occurs following trauma, but the etiology and pattern of this disorder are different from region to region. This study aims to evaluate the distribution of CSF leak in patients with maxillofacial fractures in Isfahan province, Iran.

PATIENTS AND METHODS

In this retrospective cross-sectional study, 1,287 medical files of patients admitted to a medical center with head and face injuries were evaluated during a 7-year period (2004-2010). Data was obtained using descriptive analysis.

RESULTS

Of the 1,278 patients with head and maxillofacial fractures, 16 (1.25 %) males and one (0.07 %) female had CSF leak; all these cases had skull base fracture. Of these, 52.9 % had maxillary fracture, 23.5 % nasal fracture, 41.1 % orbital fracture, 11.7 % mandibular fracture, 23.5 % frontal fracture, and 41.1 % had more than one site of fracture. 58.8 % had rhinorrhea and 41.2 % otorrhea. Of all these patients with CSF leak, 8 (47 %), 2 (11.8 %), and 7 (41.2 %) cases were treated spontaneously, using lumbar drain placement, and by surgical intervention, respectively.

CONCLUSIONS

Cerebrospinal fluid leak was observed most frequently in patients with fracture in the zygomatic and maxillary bone, and mostly exhibited itself as rhinorrhea and/or otorrhea. All cases with CSF leak had skull base fracture as well. However, post-traumatic CSF leaks are uncommon and are generally treated without surgical intervention (59 %). Distribution of CSF leak varies from one region to another and knowing this fact helps to manage the injury and prevent the complications.

Mild traumatic brain injury diagnosis frequently remains unrecorded in subjects with craniofacial fractures

BACKGROUND

Traumatic brain injuries (TBI) in subjects with craniofacial fractures are usually diagnosed by emergency room physicians. We investigated how often TBI remains unrecorded in these subjects, and whether diagnostic accuracy has improved after the implementation of new TBI guidelines.

METHODS

All subjects with craniofacial fractures admitted to Oulu University Hospital in 1999 and in 2007 were retrospectively identified. New guidelines for improving the diagnostic accuracy of TBI were implemented between 2000 and 2006. Clinical symptoms of TBI were gathered from notes on hospital charts and compared to the recorded diagnoses at discharge. Logistic regression was used to identify independent predictors for TBI to remain unrecorded.

RESULTS

Of 194 subjects with craniofacial fracture, 111(57%) had TBI, 40 in 1999 and 71 in 2007. Fifty-one TBIs (46%) remained unrecorded at discharge, 48 being mild and 3 moderate-to-severe. Subjects with unrecorded TBI were significantly less frequently referred to follow-up visits. Failures to record the TBI diagnosis were less frequent (29/71, 41%) in 2007 than in 1999 (22/40, 55%), but the difference was not statistically significant. The most significant independent predictor for this failure was the clinical specialty (other than neurology/neurosurgery) of the examining physician (p<0.001). The subject's alcohol intoxication did not hamper the diagnosis of TBI.

CONCLUSIONS

TBIs remain frequently unrecorded in subjects with craniofacial fractures. Recording of mild TBI slightly but insignificantly improved after the implementation of new guidelines.

Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases

BACKGROUND

Facial fractures and concomitant cranial injuries carry the significant potential for mortality and neurological morbidity mainly in young adults.

AIMS AND OBJECTIVES

To analyze the characteristics of head injuries and associated facial injuries, the management options and outcome following cranio-facial trauma.

METHODS

This retrospective review was performed at Justice K. S. Hegde Charitable Hospital, and associated A. B. Shetty Memorial Institute of Dental sciences, Deralakatte, Mangalore. Following Ethical Committee approval, hospital charts and radiographs of 100 consecutive patients of cranio-facial trauma managed at the Department of Oral and Maxillofacial Surgery and Neurosurgery between January 2004 and December 2004 were reviewed.

RESULTS

Majority of the patients were in the 2nd to 4th decade (79%) with a male to female ratio of -8.09:1. Road traffic accidents were the common cause of craniofacial trauma in present study (54%) followed by fall from height (30%). Loss of consciousness was the most common clinical symptom (62%) followed by headache (33%). Zygoma was the most commonly fractured facial bone 48.2% (alone 21.2%, in combination 27.2%). Majority of patients had mild head injury and managed conservatively in present series. Causes of surgical intervention for intracranial lesions were compound depressed fracture, contusion and intracranial hematoma. Operative indications for facial fractures were displaced facial bone fractures. Major causes of mortality were associated systemic injuries.

CONCLUSION

Adult males are the most common victims in craniofacial trauma, and road traffic accidents were responsible for the majority. Most of the patients sustained mild head injuries and were managed conservatively. Open reduction and internal fixation with miniplates was used for displaced facial bone fractures.

Facial Fracture Repair in the Traumatic Brain Injury Patient

PURPOSE

To review the surgical complications of patients who had facial fractures repairs in the setting of a traumatic brain injury (TBI).

PATIENTS AND METHODS

A review of all individuals admitted with the diagnosis of TBI based on an evaluation by the neurotrauma service who also underwent facial fracture repair was performed. More than 600 charts were reviewed and 99 patients met study criteria. Univariate and mulitvariate logistic regression model analysis were performed comparing the complication rate in the immediate postoperative period to the patients' age, gender, mechanism of injury, zone of facial injury, preoperative Glasgow Coma score, presence of multisystem injury, mechanism of TBI and treatment, length of time from injury to surgical repair and length of surgical procedure.

RESULTS

Of the 99 individuals studied, there was an 11% complication rate (8 minor, 3 major) in the immediate postoperative period. After univariate analysis, the length of time from injury to surgical repair, zone 1 facial injury and low Glasgow Coma score were all factors associated with increased complications. Multivariate logistic regression model analysis revealed that the odds of a patient sustaining a postoperative complication was 1.298 as the hour of procedure increased by 1 hour (95% CI, 1.065-1.582) and was 1.152 as the days of repair increased by 1 day (95% CI, 1.030-1.288).

CONCLUSIONS

The overall complication rate of facial fracture repair in the TBI patient was 11%. A prolonged surgical procedure and delay in surgical repair were associated with higher complication rates as identified by multivariate logistical regression analysis.

Réunion de neuroanesthésie-réanimation. Prise en charge anesthésique du patient en hypertension intracrânienne aiguë

Transcranial Doppler and, if possible, measurement of intracranial pressure (ICP) allow preoperative diagnosis of acute intracranial hypertension (ICH) after brain trauma. The main goal of the anaesthesiologist is to prevent the occurrence of secondary brain injuries and to avoid cerebral ischaemia. Treatment of high ICP is mainly achieved with osmotherapy. High-dose mannitol administration (1.4 to 2 g/kg given in bolus doses) may be considered a better option than conventional doses, especially before emergency evacuation of a cerebral mass lesion. Hypertonic saline seems as effective as mannitol without rebound effect and without diuresis increase. Haemostasis should be normalized before neurosurgery and invasive blood pressure monitoring is mandatory. For anaesthesia induction, thiopental or etomidate may be used. In case of ICH, halogenated and nitrous oxide should be avoided. Until the dura is open, mean arterial pressure should be maintained around 90 mmHg (or cerebral perfusion pressure around 70 mmHg). If a long-lasting (several hours) extracranial surgery is necessary, ICP should be monitored and treatment of ICH should have been instituted before.

Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma

PURPOSE

The management of persistent, post-traumatic cerebrospinal fluid (CSF) rhinorrhea and otorrhea remains a surgical challenge. Repair of CSF leaks has evolved from that of an intracranial approach to one that is primarily extracranial and endoscopic. The purpose of this retrospective analysis is to determine the incidence of persistent CSF rhinorrhea and otorrhea and assess the clinical outcomes of patients presenting to a level 1 trauma center with posttraumatic CSF leaks who were managed by both surgical and nonsurgical means.

PATIENTS AND METHODS

The records of all patients with basilar skull fractures and/or severe facial trauma presenting to a major level 1 trauma center from 1991 to 2001 were reviewed. Patients diagnosed with CSF otorrhea or rhinorrhea, who had not undergone an intracranial procedure, elevation of depressed skull fractures, or received a ventriculostomy, were identified and their demographics recorded. For purposes of statistical comparison, patients were divided into 2 groups: "leak" and "no leak." All patients in the leak group were initially observed for a period of 7 to 10 days. Persistent CSF leaks were managed by CSF diversion via lumber drainage for 5 to 7 days. Extracranial repair was performed only if lumbar drainage failed to resolve the leak.

RESULTS

Seven hundred thirty-five patients were identified who met the criteria for inclusion in the study. Thirty-four patients (incidence, 4.6%) were identified with CSF leak presenting as otorrhea (n = 25 [75.8%]) or rhinorrhea (n = 9 [26.5%]), which was diagnosed by clinical, laboratory, or radiographic examination (average age, 28.2 years; age range, 2 to 80 years; 23 males and 11 females). All patients in this study experienced successful resolution of CSF otorrhea or rhinorrhea by using a variable combination of observation, CSF diversion, and extracranial repair. There were no complications or cases of meningitis. Twenty-eight patients (84.6%) experienced uncomplicated resolution of the leak without treatment in 2 to 10 days. Persistent CSF leak, defined by drainage greater than 7 days after injury, was identified in 6 patients (incidence, 0.8%), all except 1 who underwent CSF diversion via a lumbar drain for a period of 5 to 10 days. Two of these patients were treated successfully; the remaining 4 patients required surgical procedures.

CONCLUSIONS

Post-traumatic CSF leaks are uncommon and will usually resolve without surgical intervention. Successful management in refractory cases often involves a combination of observation, CSF diversion, and/or extracranial and intracranial procedures.

Demographics and treatment options for orbital roof fractures

OBJECTIVE

The purpose of this article was to review the frequency, germane anatomy, management modalities, and complications associated with the treatment of orbital roof fractures in the pediatric and the adult population.

STUDY DESIGN

A review of the past 30 years of the English-language maxillofacial surgical literature was undertaken. Important concepts were coupled with the authors' experience to provide a synopsis of contemporary thought on this topic.

RESULTS

More than 235 articles in the oral and maxillofacial, plastic and reconstructive, otolaryngology-head and neck, ophthalmologic, oculoplastic, neurologic, and pediatric surgical literature were reviewed and assessed. From this group, 50 articles were found to contain useful information.

CONCLUSIONS

It has been estimated that 1% to 9% of all facial fractures involve the orbital roof. The typical adult with an orbital roof fracture is a man (89%-93%) who has been involved in a high-energy impact and who has sustained concomitant multisystem injuries (57%-77%). Orbital roof fractures most commonly coexist with other craniofacial injuries. In contrast, in pediatric patients with an orbital roof injury, we see nearly equal sex distribution; the typical patient in this case has a frontobasal fracture that is minimally displaced or nondisplaced (53%-93%) and has sustained concomitant multisystem injuries. The pediatric patient is usually managed by means of observation alone (53%-86%). For the adult patient, a subcranial approach to the orbital roof by means of a bitemporal flap or superior blepharoplasty incision offers wide access with minimal morbidity. Currently available titanium microscrew and miniscrew and mesh systems offer a near-ideal modality for orbital roof reconstruction. The coexisting neurocranial, frontal sinus, and supraorbital rim fractures take priority over the management of orbital roof fractures. Complications associated with orbital roof injuries can be categorized as those attributed to the following: concomitant injury, surgical access, postreconstruction volume discrepancy, muscle entrapment, hemorrhage, and/or infection.

Management of complicated neurologic injuries

Despite measures based on the Monro-Kellie principles for ICP reduction and optimization of cerebral perfusion pressure, the outcome from complicated neurologic injuries remains unsatisfactory. Many patients are "pulled through" the acute event only to remain minimally functional or vegetative for the remainder of their lives. Pharmacologic interventions to protect the brain against the toxic and metabolic consequences of neurologic injury seem to be the future of neurotrauma.

Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury

A 100-month retrospective review was undertaken to identify the population characteristics of patients with both facial and cranial fractures and to establish the relationships between them. A 4.4% incidence of cranial fractures was found in the 882 patients with facial fractures. These patients tended to be males (85%) between the ages of 16 and 30 years (54%) who were involved in motor vehicle accidents (64%). Patients with midfacial fractures predominated (70%), and these injuries were most frequently associated with fractures of the frontal (38%), sphenoid (24%), or temporal (22%) bones. No relationship was noted between mandibular fractures and cranial fractures. Midfacial fractures were related to individual cranial bone fractures by sutural attachment. The presence of cranial fractures did not play a role in the development of complications associated with facial fractures.

Posttraumatic osteotomies of the jaws

The increase in road traffic accidents as well as injuries caused by violence has resulted in an increase of fractures of the facial bones. These fractures are not always treated properly. Sometimes they are not treated at all because of their complexity or, more often, because of the associated, mainly neurological, injuries. With the advances in orthognathic surgery a variety of osteotomy techniques have become available. Originally designed to treat congenital deformities, they can also be used to improve posttraumatic malposition of the maxillofacial bones.