Orbital fractures: role of imaging

An unusual presentation of orbital encephalocele following a self-inflicted gunshot wound injury: A case report and literature review

While orbital encephaloceles secondary to orbital roof fractures, in the setting of gunshot wound injuries, are rare, it is important to discuss diagnosis, treatment, and outcomes. This comprehensive manuscript aims to accomplish these objectives.

Ultrasound technology assisted colloidal nanocrystal synthesis and biomedical applications

Non-invasive and high spatiotemporal resolution mythologies for the diagnosis and treatment of disease in clinical medicine promote the development of modern medicine. Ultrasound (US) technology provides a non-invasive, real-time, and cost-effective clinical imaging modality, which plays a significant role in chemical synthesis and clinical translation, especially in in vivo imaging and cancer therapy. On the one hand, the US treatment is usually accompanied by cavitation, leading to high temperature and pressure, so-called "hot spot", playing a significant role in sonochemical-based colloidal synthesis. Compared with the classical nucleation synthetic method, the sonochemical synthesis strategy presents high efficiency for the fabrication of colloidal nanocrystals due to its fast nucleation and growth procedure. On the other hand, the US is attractive for in vivo and medical treatment, with applications increasing with the development of novel contrast agents, such as the micro and nano bubbles, which are widely used in neuromodulation, with which the US can breach the blood-brain barrier temporarily and safely, opening a new door to neuromodulation and therapy. In terms of cancer treatment, sonodynamic therapy and US-assisted synergetic therapy show great effects against cancer and sonodynamic immunotherapy present unparalleled potentiality compared with other synergetic therapies. Further development of ultrasound technology can revolutionize both chemical synthesis and clinical translation by improving efficiency, precision, and accessibility while reducing environmental impact and enhancing patient care. In this paper, we review the US-assisted sonochemical synthesis and biological applications, to promote the next generation US technology-assisted applications.

Facial fractures: The "bottom-up" approach

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

Prediction of Enophthalmos in Medial Orbital Wall Fracture: Suggested Coordinate Plane for Making Surgical Decisions

BACKGROUND

Enophthalmos is one of the most distressing complications of blowout orbital fractures. Although several studies have been conducted on the topic of indications of early surgical correction, none have been performed using a set of measurable parameters.

METHODS

The study quantitatively examined orbital fracture areas (OFA) and volumes (OFV) retrospectively of 242 patients with isolated medial orbital wall fractures that were treated conservatively during a 12-year period (from 2009 to 2021). Three plastic surgeons measured enophthalmos >6 months after trauma. The correlations between parameters and enophthalmos in the study cohort were analyzed. In addition, patients treated operatively, and nonoperatively were compared with assess the suitability of the predictive model.

RESULTS

Significant correlations were observed between several parameters and late enophthalmos. Total 2.59 cm 2 of OFA (ie, OFA >2.59 cm 2 ) or 1.45 cm 3 of OFV (ie, OFV >1.45 cm 3 ) corresponds to 2 mm of enophthalmos. Multiple regression analysis revealed the following coefficients: -0.208 is a constant ( P <0.001), with 0.695 and 0.372 for OFA and OFV, respectively ( P <0.001 for both OFA and OFV).

CONCLUSIONS

The study shows that enophthalmos can be more accurately predicted when OFA and OFV are simultaneously considered in patients with isolated medial wall fractures. Finally, an algorithm and a "blowout fracture coordinate plane" was proposed to aid treatment decision-making in isolated medial wall fractures.

Accuracy of linear-probe ultrasonography in diagnosis of infraorbital rim fractures

BACKGROUND

Maxillofacial fractures are a common cause of visits to emergency department, accounting for more than 400,000 annual visits in the United States. Gold standard diagnostic tool is conventional computerized tomography (CT) or 3DCT reconstruction. However, the disadvantages of CT are radiation exposure, unavailable in some hospital and expensiveness. Whereas the bony structures overlap is a problem in diagnostic when using plain film X-ray. The objective of this study is to show the accuracy of a linear-probe ultrasound compared to computed tomography and plain film X-ray in diagnosis of infraorbital rim fracture.

METHODS

Patients clinically suspected of an inferior orbital rim fracture underwent linear-probe ultrasonographic investigation, plain film X-ray and CT. CT was used as gold standard in this diagnostic study. A radiologist and senior resident of plastic surgery were the examiner and interobserver for comparison.

RESULT

A total of 34 patients with suspected infraorbital rim fractures were investigated. Sensitivity of the linear-probe ultrasonography versus CT in the detection of infraorbital rim fracture was 92.9% (95% CI 66.1-99.8), specificity was 90.0% (95% CI 68.3-98.8), positive predictive value was 86.7% (95% CI 59.5-98.3), negative predictive value was 94.7% ( 95% CI 74.0-99.9), accuracy 91%.

CONCLUSION

Linear probe ultrasonography is a good diagnostic tool and has better reliability than the plain film X-ray and can be used as alternative to CT in inferior orbital rim fracture.

Decreased gray matter volume and increased white matter volume in patients with neovascular age-related macular degeneration: a voxel-based morphometry study

OBJECTIVE

To measure white and gray matter volume (WMV, GMV) in patients with neovascular age-related macular degeneration (nAMD) using voxel-based morphometry (VBM).

MATERIAL

Eighteen patients (9 men, 9 women) with nAMD and 18 (9 men, 9 women) healthy controls (HCs) aligned were recruited. Functional magnetic resonance imaging (fMRI) and VBM of three-dimensional T1 brain images were analyzed. And we also apply t-tests to look for GMV and WMV differences between groups. Correlation analysis was utilized to probe the connection between observational GMV and WMV values of diverse brain areas and the severity of HADS (hospital anxiety and depression scale). Also, distinctions between nAMD and HCs in GMV can be presented with the help of a ROC (receiver operating characteristic) curve.

RESULTS

Compared with HCs, GMV values were significantly lower in patients with neovascular age-related macular degeneration in the right inferior frontal gyrus, temporal pole of left superior temporal gyrus, left superior temporal gyrus, left middle frontal gyrus, left anterior cingulate and para cingulate gyrus. While WMV was slightly increased in these areas. HADS (hospital anxiety and depression scale) scores portrayed a non-linear correlation with the GMV value of the right inferior frontal gyrus, left middle frontal gyrus, left anterior cingulate and paracingulate gyrus of the nAMD group (r=-0.6629, P=0.0027)(r=-0.9451, P<0.0001)(r=-0.6183, P=0.0062). Moreover, the ROC curve analysis of the mean VBM values for altered brain regions indicated high diagnostic accuracy.

CONCLUSION

These results indicated that patients with nAMD have abnormal GMV and WMV and formed a basis for future research on pathological mechanisms in this disease. Moreover, decreased gray matter volume in particular brain regions might be associated with choroidal neovascularization and abnormal HADS score. It might help to explain the pathological mechanism of anxiety and depression in patients with nAMD.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery

BACKGROUND

Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation.

METHODS

The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures.

RESULTS

One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02).

CONCLUSIONS

The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Retrospective Cohort Study of Frequency and Patterns of Orbital Injuries on Whole-Body CT with Maxillofacial Multi-Slice CT

Background: High-impact trauma frequently leads to injuries of the orbit, but literature focusing on the viscerocranium rather than the neurocranium is underrepresented. Methods: Retrospective cohort study (2006–2014) at an urban level 1 trauma center assessing the frequency and typical patterns of orbital injuries on whole-body computed tomography (WBCT) with maxillofacial multi-slice CT (MSCT) after severe trauma. (1) Screening of consecutive WBCT cases for dedicated maxillofacial MSCT. (2) Examination by two independent experts’ radiologists for (peri-/)orbital injuries. (3) Case review for trauma mechanisms. Results: 1061 WBCT were included revealing 250 (23.6%) patients with orbital injuries. Less than one-quarter (23.3%) of patients showed osseous and 9.5% showed soft tissue injuries. Combined osseous and soft tissue lesions were present in 39.2% of orbital injuries, isolated soft tissue injuries were rare. Single- or two-wall fractures of the orbit were prevalent, and the orbital floor was affected in 67% of fractures. Dislocated extraocular muscles (44.6%), deformation of the ocular globe (23.8%), and elongation of the optic nerve (12.9%) were the most frequently soft tissue findings. Vascular trauma was suspected in 15.8% of patients. Conclusions: Orbital trauma was confirmed in 23.6% of cases with suspected facial injuries after severe trauma. Concomitant soft tissue injuries should be excluded explicitly in cases with orbital fractures to prevent loss of vision or ocular motility.

Ocular siderosis: a misdiagnosed cause of visual loss due to ferrous intraocular foreign bodies-epidemiology, pathogenesis, clinical signs, imaging and available treatment options

Purpose

The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, clinical signs, imaging and treatment of ocular siderosis (OS).

Methods

A computerized search from inception up to March 2020 of the online electronic database PubMed was performed using the following search strings: “ocular siderosis” and “siderosis bulbi”. The reference list in each article was analysed for additional relevant publications.

Results

OS is an uncommon cause of visual loss due to a retained ferrous intraocular foreign body (IOFB). It may develop from 18 days to years after a penetrating trauma that usually occurs during hammering. On average, patients are 22–25 years old, and the vast majority are male. The most common cause of OS development is delayed presentation by the patient or missed diagnosis of IOFB after trauma. The pathophysiology is not fully understood; nevertheless, iron deposition causes hydroxyl radical formation, which damages photoreceptors and retinal pigment epithelium. Moreover, iron damages retinal vessels with consequent inner retinal layers degeneration. The most frequent signs are iris heterochromia, pupillary mydriasis, cataract development and retinal arteriolar narrowing with pigmentary retinal degeneration. Electroretinogram signs, in particular, b-wave amplitude reduction, arise earlier than clinical signs. Orbital CT scans and ultrasonography play an essential role in detecting IOFBs. Treatment depends on the IOFB location and OS development. However, it is crucial to remove the IOFB after OS development because visual acuity and clinical signs may improve. Anterior segment IOFBs can be dislodged using an intraocular magnet (IOM) or forceps through limbal paracentesis. In contrast, posterior segment IOFBs require a pars plana vitrectomy and IOM or forceps to be removed through an enlarged sclerotomy or the limbus.

Conclusion

Recommending the usage of protective glasses and spreading knowledge about OS may further benefit patient care.

ACR Appropriateness Criteria® Major Blunt Trauma

This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

Computed tomography based analysis of the lamina papyracea variations and morphology of the orbit concerning endoscopic surgical approaches

Introduction

Radiologic evaluation is mandatory to assess the type of endoscopic approach concerning sinonasal pathology and reconstruction of fractured defects before any treatment modalities are instituted related to medial wall of the orbit.

Objective

The goal was to provide improved understanding of the lamina papyracea variations and the relationship with the orbital morphometry.

Methods

This retrospective study was performed using computed tomography scans of 200 orbits and results were compared with respect to age, sex, laterality and LP variations.

Results

Lamina papyracea variations were categorized as type A, 80.5% (161/200); type B, 16% (32/200); type C, 3.5% (7/200). For medial wall the anterior and posterior lamina papyracea heights and angles were found as 17.14 mm, 147.88° and 9.6 mm, 152.72°, respectively. Also, the length of the lamina papyracea, the mean area of the orbital floor, medial wall, lamina papyracea and orbital entrance were 33.3 mm, 7.2 cm², 6.89 cm², 4.51 cm² and 12.46 cm² respectively. The orbital height and width were measured as 35.9 mm and 39.2 mm respectively. The mean orbital cavity depth was 46.3 mm from optic foramen to the orbital entrance and the orbital volume was 19.29 cm³. We analyzed the morphometric measurements tending to increase with aging and greater in men and the relationship of them with lamina papyracea types.

Conclusion

Precise knowledge of the lamina papyracea anatomy using computed tomography is essential for safer and more effective surgery and preforming the dimensions of an implant. In this way, the postoperative complications can be decreased and the best outcome can be provided.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures.

Scapular fractures: a common diagnostic pitfall

Scapular fractures are one of the most difficult fractures to diagnose on radiographs. Detection can be challenging because of the obscuration by the overlying structures or incomplete imaging due to difficult patient collaboration. Familiarity with imaging characteristics of these abnormalities will allow radiologists to better diagnose and characterize scapular fractures. Three-dimensional computed tomographic scans are considered the gold standard for scapular diagnoses. Treatment strategies differ depending on the type of scapular fractures, but the site and degree of displacement will determine whether surgical intervention should be considered. Complications can occur in fractures that are undiagnosed or improperly evaluated. The purpose of this article is to describe imaging features of traumatic scapular injury, and discuss the role of diagnostic imaging in clinical decision making after shoulder trauma. (www.actabiomedica.it)

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Imaging modalities for midfacial fractures

The middle third of the facial skeleton is one of the most complex areas of the human body. A critical factor determining the successful treatment of midfacial fractures is an early and correct diagnosis. Assessment and management of the traumatized patient requires rapid evaluation and decision making. Imaging for the evaluation of patients with midfacial fractures has contributed to achieving an accurate diagnosis and a subsequent successful management. It requires a knowledge of those imaging modalities and projections that provide the most information with the least exposure of radiation to the patient. Conventional radiography has been used successfully for many years although advanced imaging methods such as—three-dimensional computed tomography, magnetic resonance imaging, and cone beam computed tomography have been applied more recently. In this article, we will take a relook at various modalities to image midfacial fractures, and discuss the rationale for selection of those procedures that offer the greatest diagnostic information.

Acute post-traumatic encephalocele in a child: CT and MRI features

Orbital trauma is a commonly encountered entity in clinical practice, especially in cases of head trauma. Although fractures of the orbit are rare, they can present in an emergency setting owing to associated complications such as orbital encephaloceles. We present a case of a paediatric male patient who presented with post-traumatic proptosis and diminution of vision and was diagnosed with orbital encephalocele. The child's vision recovered completely and proptosis of the eye decreased, compared with the time of presentation. Despite persistent counselling, the patient and his parents did not give consent for surgical correction and he was discharged as leaving against medical advice. Post-traumatic orbital encephaloceles are caused as a result of blunt cranial trauma. Early treatment and diagnosis is extremely important in the optimum management and good long-term prognosis of the patient.

Errors in imaging patients in the emergency setting

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

Violence-related periorbital trauma with a retained foreign body: a case report

Background

Orbital fracture usually occurs as a result of blunt orbital and facial trauma and may involve ocular injuries. International studies on orbital floor fracture show several differences in epidemiology, diagnostic criteria, surgical treatment modalities, and complication rates; therefore, any comparison should be made with caution. Here we describe an unusual case involving a 19-year-old man with violence-related periorbital trauma, wherein a foreign body (a plastic pen cap) traversed the median wall of the maxillary sinus and penetrated the lower turbinate.

Case presentation

A 19-year-old Caucasian man was referred to our department with localized pain and swelling in the left suborbital region following a physical fight in May 2014. A clinical examination revealed no abnormalities in his eyeballs or eye movement, palpation of the orbital contour revealed no fractures, and ophthalmological evaluation showed no evidence of diplopia. A computed tomography scan revealed fractures in the left orbital floor, periorbital tissue herniation without muscular entrapment and left maxillary hemosinus were observed. A hypodense soft tissue mass was lodged in the left orbital floor, which extended to the median wall of the maxillary sinus and penetrated the left lower turbinate. Surgical exploration of the foreign body was conducted, revealing the foreign body to be a pen cap.

Conclusions

History or clinical examination alone may be inadequate to raise the suspicion of a retained periorbital foreign body in a situation of orbital region trauma. Computed tomography is important for the evaluation of periorbital injuries, especially because it could reveal the presence of a foreign body. Periorbital foreign bodies can be observed distinctly on computed tomography, which remains the most sensitive study and should be the first imaging modality in such cases.

Optimized imaging of the midface and orbits

A variety of imaging techniques are available for imaging the midface and orbits. This review article describes the different imaging techniques based on the recent literature and discusses their impact on clinical routine imaging. Imaging protocols are presented for different diseases and the different imaging modalities.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons

PURPOSE

In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data.

MATERIALS AND METHODS

An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics.

RESULTS

The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia.

CONCLUSIONS

Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

Imaging of the Postoperative Orbit

Imaging evaluation of the postoperative orbit remains challenging even for the expert neuroradiologist. This article provides a simplified framework for understanding the complex postoperative appearances of the orbit, in an attempt to enhance the diagnostic accuracy of postoperative computed tomography and MR imaging of the orbit. Readers are familiarized with the normal appearances of common eye procedures and orbit reconstructions to help avoid interpretative pitfalls. Also reviewed are imaging features of common surgical complications, and evaluation of residual/recurrent neoplasm in the setting of oncologic imaging surveillance.

Diagnosis and imaging of orbital roof fractures: a review of the current literature

Isolated adult orbital roof fractures are uncommon, and the majority of them are typically associated with extensive craniofacial, ophthalmologic, and other body injuries. It is crucial to make an appropriate diagnosis of orbital roof fracture if present. Therefore, the aim of this article was to review the current literature about diagnosis and imaging of orbital roof fracture to obtain current indications. A systematic review of articles published between January 1990 and August 2013 was performed. Early diagnosis of orbital roof fractures can reduce the incidences of intracranial and ocular complications. CT scan still plays a major role in the assessment of acute orbital trauma. Careful assessment and reporting of the CT scan findings are important. In fact, the clinicians managing the patient with acute head and facial trauma should be familiar with the common findings of CT scan in case of an orbital roof fracture.

Injuries of the globe: what can the radiologist offer?

Traumatic ocular injuries are a significant cause of blindness and visual deficits. In the setting of acute orbital trauma, urgent ophthalmologic evaluation and intervention are critical in preserving vision. However, in the acute trauma setting, clinical evaluation of the globe may be difficult in the presence of surrounding periorbital soft-tissue swelling and other associated injuries, and patient cooperation may be limited because of unresponsiveness, altered mentation, or sedation. Often, rapid access to imaging is part of the initial diagnostic evaluation, and radiologists may be the first to identify traumatic injuries of the globe. Because of this, radiologists should be familiar with normal orbital and globe anatomy at various imaging modalities and have a thorough understanding of the various patterns of ocular injury and their imaging appearances. Radiologists should also be familiar with the various mimics of ocular injury, including congenital and acquired conditions that may alter the shape of the globe, various types of ocular calcifications, and the different types of material used to treat retinal detachment. Such knowledge may help radiologists make accurate diagnoses, which facilitates prompt and appropriate patient care.

Foreign bodies in the maxillofacial region: assessment with multidetector computed tomography

Maxillofacial region is an anatomically complex area, representing a crossroads of different systems and apparatus. It is defined as the anatomical region lying on the facial skeleton from the inferior outline of maxilla up to an ideal plane passing through the skull base and the inion point, posteriorly. In this area, the digestive and respiratory systems connect to themselves and open in the mouth and sino-nasal cavities. Even the orbits with the ocular globes and their surrounding tissues lie in the same area. Despite the little exposed surface, the chance of penetrating injuries to this site is at least similar to other regions of the body due to the "pivotal role" of the face in human relations. Moreover, the external openings of respiratory and digestive systems and the orbital cavities represent an easy way in for foreign bodies (FBs). Based on the access paths, it is possible to distinguish ingested, inhaled, penetrating, and iatrogenic (owing to surgery) FBs. FB may stop in oral and ocular cavities, or proceed deeply, reaching the surrounding soft tissues, the facial bones, or other cavities such as sino-nasal region, mouth, orbits, and further spaces of the head and neck region, like infratemporal fossa, parapharyngeal space, and sphenopalatine fossa. Furthermore, FBs accidentally introduced and lost in visceral cavities (mouth, ear, and nose), particularly in pediatric subjects, may be quickly removed during direct inspection.

Comparison of Absorbable Mesh Plate versus Titanium-Dynamic Mesh Plate in Reconstruction of Blow-Out Fracture: An Analysis of Long-Term Outcomes

Background

A blow-out fracture is one of the most common facial injuries in midface trauma. Orbital wall reconstruction is extremely important because it can cause various functional and aesthetic sequelae. Although many materials are available, there are no uniformly accepted guidelines regarding material selection for orbital wall reconstruction.

Methods

From January 2007 to August 2012, a total of 78 patients with blow-out fractures were analyzed. 36 patients received absorbable mesh plates, and 42 patients received titanium-dynamic mesh plates. Both groups were retrospectively evaluated for therapeutic efficacy and safety according to the incidence of three different complications: enophthalmos, extraocular movement impairment, and diplopia.

Results

For all groups (inferior wall fracture group, medial wall fractrue group, and combined inferomedial wall fracture group), there were improvements in the incidence of each complication regardless of implant types. Moreover, a significant improvement of enophthalmos occurred for both types of implants in group 1 (inferior wall fracture group). However, we found no statistically significant differences of efficacy or complication rate in every groups between both implant types.

Conclusions

Both types of implants showed good results without significant differences in long-term follow up, even though we expected the higher recurrent enophthalmos rate in patients with absorbable plate. In conclusion, both types seem to be equally effective and safe for orbital wall reconstruction. In particular, both implant types significantly improve the incidence of enophthalmos in cases of inferior orbital wall fractures.

Coexistence of cavernous hemangioma and other vascular malformations of the orbit. A report of three cases

Coexistence of orbital cavernous hemangioma and other vascular malformations is unusual and few cases have been reported. We describe the clinical and radiological features of three cases of orbital cavernous hemangiomas associated with other vascular malformations, selected reviewing a series of 181 cases of cavernous hemangiomas. All patients were males (age ranging from 43 to 67 years) without vascular systemic disorders and/or a clinical syndrome. They experienced slow progressive exophthalmos. One of them developed acute pulsatile proptosis (case 2), while another experienced slow progressive diplopia (case 3). In one case vascular lesions were bilateral (case 3) and in two patients two different lesions coexisted in the same orbit (cases 1 and 2). All patients underwent surgical excision, which was partial in two cases. Two patients had cavernous hemangiomas in association with a venous malformation (a varix in case 1 and a lymphangioma in case 2), while in the other ones (case 3) cavernous hemangioma was associated with a low-flow arteriovenous malformation. No patient denied visual impairment postoperatively. Few cases of orbital cavernous hemangiomas coexisting with other vascular malformations have been reported in the literature. This entity seems to be an association of different variants of orbital vascular malformations, presenting with a wide spectrum of clinical forms and probably with the same pathogenesis.

Disease activity in Graves' ophthalmopathy: diagnosis with orbital MR imaging and correlation with clinical score

In Graves' ophthalmopathy (GO) it is important to distinguish acute inflammation at an early stage, responsive to immunosuppressive treatment, from inactive fibrotic end stage disease, unresponsive to the same treatment. The purpose of this study was to identify the most relevant signal intensities on orbital MR imaging with contrast administration both to classify patients according to their clinical activity score (defined by a cut-off value of 3) and to make a prediction of patient's CAS. Such threshold was considered as widely used in literature. Sixteen consecutive patients with a diagnosis of GO in different phases of thyroid disease based on clinical and orbital MR imaging signs, and six normal volunteers were examined. Orbital MR imaging was performed on a 1.5 Tesla MR Unit. MR scans were assessed by an experienced neuroradiologist, blinded to the clinical examinations. We found a statistical correlation between CAS and both STIR and contrast enhanced T1-weighted sequences. There was also a statistically significant correlation between STIR and contrast-enhanced T1 images disclosing the possibility of avoiding the injection of contrast medium. Our study proved that signal intensity values on STIR sequence increase in the inflammatory oedematous phase of disease. We confirmed the correlation between signal intensities on this sequence and CAS, showing an increase in signal intensity proportional to the CAS value. So we validated MRI use to establish the activity phase of disease more sensitively than CAS alone.

Cone beam computed tomography for imaging orbital trauma--image quality and radiation dose compared with conventional multislice computed tomography

We compared the image quality and radiation dose to the lens of the eye in patients with suspected orbital fractures who were imaged using cone beam computed tomography (CBCT) or conventional multislice computed tomography (CT). Although CBCT has a lower radiation dose than conventional CT, it is not known whether the image quality is comparable for diagnostic purposes. We identified fractures of the orbit (floor or roof, or both) in 6/10 patients who were scanned using CBCT and in 5/10 patients who were scanned using multislice CT (orbital floor and medial wall). Impingement of the rectus muscle on fracture lines was identified with both techniques, but retro-orbital haemorrhage was detected only on multislice CT. The mean radiation dose to the lens of the eye was 42% lower (range 23-53, SD 10) for CBCT than for multislice CT (p<0.001), and the effective dose (a measure of the risk of developing a radiation-induced cancer) was also significantly lower. CBCT can therefore be used to diagnose orbital fractures, and is associated with a significantly lower radiation dose than multislice CT.

The Correlation between the Degree of Enophthalmos and the Extent of Fracture in Medial Orbital Wall Fracture Left Untreated for Over Six Months: A Retrospective Analysis of 81 Cases at a Single Institution

Background

In patients with medial orbital wall fracture, predicting the correlation between the degree of enophthalmos and the extent of fracture is essential for deciding on surgical treatment. We conducted this retrospective study to identify the correlation between the two parameters.

Methods

We quantitatively analyzed the correlation between the area of the bone defect and the degree of enophthalmos on computed tomography scans in 81 patients with medial orbital wall fracture who had been left untreated for more than six months.

Results

There was a significant linear positive correlation between the area of the medial orbital wall fracture and the degree of enophthalmos with a formula of E=0.705A+0.061 (E, the degree of enophthalmos; A, the area of bone defect) (Pearson's correlation coefficient, 0.812) (P<0.05). In addition, that there were no cases in which the degree of enophthalmos was greater than 2 mm when the area of the medial orbital wall fracture was smaller than 1.90 cm².

Conclusions

Our results indicate not only that 2 mm of enophthalmos corresponds to a bone defect area of approximately 2.75 cm² in patients with medial orbital wall fracture but also that the degree of enophthalmos could be quantitatively predicted based on the area of the bone defect even more than six months after trauma.

Sources of error in emergency ultrasonography

BACKGROUND

To evaluate the common sources of diagnostic errors in emergency ultrasonography.

METHODS

The authors performed a Medline search using PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the common sources of errors in diagnosis with specific reference to emergency ultrasonography. The search design utilized different association of the following terms : (1) emergency ultrasonography, (2) error, (3) malpractice and (4) medical negligence. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 171 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 48 selected articles was reviewed.

RESULTS

Several studies indicate that the etiology of error in emergency ultrasonography is multi-factorial. Common sources of error in emergency ultrasonography are: lack of attention to the clinical history and examination, lack of communication with the patient, lack of knowledge of the technical equipment, use of inappropriate probes, inadequate optimization of the images, failure of perception, lack of knowledge of the possible differential diagnoses, over-estimation of one's own skill, failure to suggest further ultrasound examinations or other imaging techniques.

CONCLUSIONS

To reduce errors in interpretation of ultrasonographic findings, the sonographer needs to be aware of the limitations of ultrasonography in the emergency setting, and the similarities in the appearances of various physiological and pathological processes. Adequate clinical informations are essential. Diagnostic errors should be considered not as signs of failure, but as learning opportunities.

A rare case of intraosseous lipoma involving the sphenoclival region

We describe the case of a 23-year-old man whose CT scan revealed a hypodense lesion reshaping the superior and middle third of the clivus and partially invading the sphenoidal sinus. MRI showed an irregular-shaped lesion occupying the body of the sphenoid bone, involving the superior and middle third of the clivus and sprouting into the sphenoid sinus. The lesion was hyperintense on T1- and T2-weighted sequences with a thin peripheral rim of hypointensity, without enhancement after i.v. gadolinium injection. The pathology report confirmed an intraosseus lipoma. Intraosseous lipomas involving the spheno-clival region are extremely rare. CT and MRI scan interpretation can be troublesome but this rare pathology has to be considered in the differential diagnosis.

Basilar artery hypoplasia

A rare case of segmental hypoplasia of the basilar artery is described in a 49-year-old man with transient vertebrobasilar ischemia, explored by magnetic resonance imaging (MRI) and digital angiography (DA). The embryology, clinical relevance and magnetic resonance findings of this arterial anomaly are discussed, with a review of six previously reported cases. Segmental aplasia was suggested in our case by magnetic resonance, and subsequently confirmed not only by time-of-flight magnetic resonance, but also by DA. Only ultrathin-slice T2-weighted images revealed the real finding of basilar artery hypoplasia. This sequence, not employed in previously reported cases, is mandatory to allow a clear differential diagnosis between basilar artery aplasia and hypoplasia.

A wander through the land of the orbit

This article shows the pathological and physiological images of the orbit, which each radiologist will commonly see in his or her everyday CT scan practice. It explains the images, following the course of the patient's trajectory through imaging as complications develop or in the post-treatment monitoring of some common disorders (orbital trauma, retinal detachment, postoperative appearances).