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Siyanaki MRH, Azab MA, Lucke-Wold B. Traumatic Optic Neuropathy: Update on Management. ENCYCLOPEDIA 2023; 3:88-101. [PMID: 36718432 PMCID: PMC9884099 DOI: 10.3390/encyclopedia3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Traumatic optic neuropathy is one of the causes of visual loss caused by blunt or penetrating head trauma and is classified as both direct and indirect. Clinical history and examination findings usually allow for the diagnosis of traumatic optic neuropathy. There is still controversy surrounding the management of traumatic optic neuropathy; some physicians advocate observation alone, while others recommend steroid therapy, surgery, or both. In this entry, we tried to highlight traumatic optic neuropathy's main pathophysiologic mechanisms with the most available updated treatment. Recent research suggests future therapies that may be helpful in traumatic optic neuropathy cases.
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Affiliation(s)
| | - Mohammed A. Azab
- Department of Neurosurgery, University of Cairo University, Cairo 12613, Egypt
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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Sommer F, Brand M, Scheithauer MO, Hoffmann TK, Theodoraki MN, Weber R. [Diagnosis and Treatment in frontobasal fractures]. HNO 2023; 71:35-47. [PMID: 36525033 DOI: 10.1007/s00106-022-01256-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 12/23/2022]
Abstract
Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.
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Affiliation(s)
- F Sommer
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland.
| | - M Brand
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - M O Scheithauer
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - T K Hoffmann
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - M-N Theodoraki
- Universitätsklinik für Hals‑, Nasen‑, Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - R Weber
- Hals-Nasen-Ohrenklinik des Städtischen Klinikums Karlsruhe, Karlsruhe, Deutschland
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Chantrey J, Ryder TJ. Assessing Adult Patients with Facial Deformities for Injectable Treatment: Do Current Classification Systems and Methodologies Meet Important Patient Needs? Dermatol Surg 2022; 48:1185-1190. [PMID: 36342249 DOI: 10.1097/dss.0000000000003554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many individuals are affected by facial deformities. Injectable aesthetic treatments can often be used to improve appearance and/or dynamic function. However, to best meet the needs of these patients, broadly applicable methodologies are required for classifying the deformity, assessing severity, and developing a treatment strategy. OBJECTIVE To assess whether any published systems could be used for this purpose. METHODS Thirty-eight searches were conducted in PubMed (1999-2019; in English). Forty-two publications were identified describing novel classification systems for adult facial deformity. They were analyzed against a checklist of 10 characteristics defining an "optimal" system-based on appropriate anatomical coverage, wide usability across types of deformity, user-friendliness, applicable underlying methodology, and ability to guide treatment with injectables. RESULTS None of the systems met more than 7 of the 10 checklist criteria; none were usable across multiple types of deformity or provided a recommendation for treatment with injectables. CONCLUSION There remains a need for a broadly applicable system for classifying adult facial deformities ahead of injectable therapy. The checklist provides a developmental framework. With the increasing popularity and accessibility of injectables, this diverse and complex demographic is at risk of mismanagement without superior methods for devising treatment strategies.
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Three-Dimensional Evaluation of the Frontal Sinus in Koreans. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159605. [PMID: 35954963 PMCID: PMC9368756 DOI: 10.3390/ijerph19159605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 12/10/2022]
Abstract
(1) Background: Among the four paranasal sinuses, the frontal sinus is in the frontal bone. Recent research trends have been focusing on identifying sex based on the frontal sinus. Thus, this study aimed to provide reference data for the frontal sinus in Korean adults by comparing their sizes using a 3D program. Moreover, this study examined the correlation between the size of the frontal sinus and the length of cranial bone. (2) Methods: Cone-beam computed tomography (CBCT) data were obtained from 60 (male 30, female 30) patients in their 20 s who visited the Department of Dankook University Hospital (DKUDH IRB 2020-01-007). The provided patient CBCT data were utilized to reconstruct the patients’ frontal sinuses and cranial bones in 3D using the Mimics (version 22.0, Materialise, Leuven, Belgium) 3D program. All measurements were analyzed using SPSS (ver. 23.0, IBM Corporation, Armonk, NY, USA). (3) Results: By comparing the frontal sinus size of Korean adults according to sex using a 3D program, this study revealed that males had larger frontal sinuses than females. (4) Conclusions: The findings of this study could help in preventing complications that occur in various clinical treatments and analyzing the growth of the frontal sinus in the future.
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Patel KA, Holmes S, Stephens JR. Mathematical analysis of fracture configuration in predicting outcome in complex anterior skull base trauma. Br J Oral Maxillofac Surg 2022; 60:639-644. [PMID: 35346523 DOI: 10.1016/j.bjoms.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
Craniofacial trauma involving the anterior skull base produces a heterogenous injury with variance in fracture pattern, complexity and outcome. Variance is influenced by the biomechanical properties of the craniofacial construct and by the magnitude and vector of the impacting energy. Fractal dimension and other metrics applied to individual fracture patterns allows quantification of fracture complexity and severity, which can be used to correlate with neurological outcome. Frontobasal fractures from 81 patients admitted to two UK major trauma centres were analysed. Patients were divided into two groups: those with anteriorly-based vectors of impact and those with laterally-based vectors. Osseous disruption was quantified by: fractal dimension, fracture length, number of termini, and number of nodes, and then compared with neurological outcome using first recorded Glasgow Coma Score (GCS), and requirement for intubation. As fracture length increased, fractures from anterior impacts became more complex and reticulated compared with lateral impacts; fractal dimension also increased more rapidly for anterior impacts. Longer fracture length in both groups was associated with a significantly lower GCS, and increased requirement for intubation (p < 0.001 and p < 0.001 respectively). Fracture propagation and severity of head injury was different in anterior-directed trauma compared to lateral-directed trauma. Consequently, we suggest that the central region of the anterior skull base acts to primarily absorb impact force thereby behaving as a protective ' crumple zone ' . In severe mechanisms the protective mechanism is exceeded and the fracture length tended to that of the lateral group worsening prognosis.
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Affiliation(s)
- Krishna A Patel
- Craniofacial Trauma Research Group, Queen Mary University of London, UK
| | - Simon Holmes
- Department of Orthodontics, Oxford University Hospitals NHS Foundation Trust, UK.
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Frontal Sinus Fractures: Evidence and Clinical Reflections. Plast Reconstr Surg Glob Open 2022; 10:e4266. [PMID: 35450261 PMCID: PMC9015196 DOI: 10.1097/gox.0000000000004266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
Background: Despite significant advances in the management of frontal sinus fractures, there is still a paucity of large-cohort data, and a comprehensive synthesis of the current literature is warranted. The purpose of this study was to present an evidence-based overview of frontal sinus fracture management and outcomes. Methods: A comprehensive literature search of PubMed and MEDLINE was conducted for studies published between 1992 and 2020 investigating frontal sinus fractures. Data on fracture type, intervention, and outcome measurements were reported. Results: In total, 456 articles were identified, of which 53 met our criteria and were included in our analysis. No statistically significant difference in mechanism of injury, fracture pattern, form of management, or total complication rate was identified. We found a statistically significant increase in complication rates in patients with nasofrontal outflow tract injury compared with those without. Conclusions: Frontal sinus fracture management is a challenging clinical situation, with no widely accepted algorithm to guide appropriate management. Thorough clinical assessment of the fracture pattern and associated injuries can facilitate clinical decision-making.
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Srinivasa R, Furtado SV, Sansgiri T, Vala K. Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center—A Retrospective Study. J Neurosci Rural Pract 2022; 13:60-66. [PMID: 35110921 PMCID: PMC8803529 DOI: 10.1055/s-0041-1740615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Abstract
Aim We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures.
Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose.
Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant (p < 0.001).
Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.
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Affiliation(s)
- Rakshith Srinivasa
- Department of Neurosurgery, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
| | - Sunil V. Furtado
- Department of Neurosurgery, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
| | - Tanvy Sansgiri
- Department of Oral and Maxillo-facial Surgery, MS Ramaiah Dental College and Hospital, Bangalore, Karnataka, India
| | - Kuldeep Vala
- Department of Neurosurgery, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
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Adams A. Imaging of Skull Base Trauma: Fracture Patterns and Soft Tissue Injuries. Neuroimaging Clin N Am 2021; 31:599-620. [PMID: 34689935 DOI: 10.1016/j.nic.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article provides an overview of the patterns of skull base trauma and provides a review of the pertinent soft tissue injuries and complications that can ensue. A brief review of skull base anatomy is provided with subsequent focus on the important findings in anterior, central, and posterior skull base trauma.
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Affiliation(s)
- Ashok Adams
- BartsHealth NHS Trust, Queen Mary University of London, Neuroradiology Department, Royal London Hospital, Whitechapel Rd, London E1 1BB, UK.
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A Review of Frontal Orbital and Frontal Sinus Fractures and Associated Ocular Injuries - Level I Trauma Center - University Hospital Experience. J Craniofac Surg 2021; 32:1615-1618. [PMID: 33741886 DOI: 10.1097/scs.0000000000007422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Traumatic frontal fractures result from high force injuries and can result in significant morbidity and mortality. The purpose of the current study is to evaluate our Montreal General Hospital (MGH) experience with frontal bone fractures. METHODS A comprehensive review of our trauma database was performed. All adult patients (>18 years) presenting with a diagnosis of frontal sinus fracture were identified. A thorough retrospective electronic medical records search was performed and relevant data extracted. Specifically, all cases of ocular injury or sequelae were identified and an in-depth review was performed. RESULTS Between 2008 and 2014, 10,189 trauma patients presented to the MUHC Level 1 trauma center. A total of 1277 patients presented with a facial fracture and 140 had a frontal sinus fracture. The mean age was 43.5 years, 90% were male and the mean hospitalization time was 16.2 days. A significant proportion of patients suffered concomitant craniomaxillofacial fractures including orbital (79%), maxillary (66%), nasal (64%), zygomaticomaxillary complex (34%), nasoorbitoethmoid (31%), Lefort types I-III (18%), and mandibular (8%). Associated cervical spine injuries were documented in 16% of patients. Ocular injuries were present in 30% of subjects. 26% of patients had some form of permanent sequelae from their trauma, mainly neurological. CONCLUSIONS Due to the intimate association of the frontal bones with the brain and the orbits, frontal sinus fractures demand a sophisticated multidisciplinary craniofacial surgical approach. Given the high rate of ocular injury of 30% as well as severe systemic injuries, the authors propose a modified treatment algorithm for these complex cases.
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Abstract
BACKGROUND Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. METHODS The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. RESULTS In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. CONCLUSIONS Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Dreizin D, Sakai O, Champ K, Gandhi D, Aarabi B, Nam AJ, Morales RE, Eisenman DJ. CT of Skull Base Fractures: Classification Systems, Complications, and Management. Radiographics 2021; 41:762-782. [PMID: 33797996 DOI: 10.1148/rg.2021200189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
As advances in prehospital and early hospital care improve survival of the head-injured patient, radiologists are increasingly charged with understanding the myriad skull base fracture management implications conferred by CT. Successfully parlaying knowledge of skull base anatomy and fracture patterns into precise actionable clinical recommendations is a challenging task. The authors aim to provide a pragmatic overview of CT for skull base fractures within the broader context of diagnostic and treatment planning algorithms. Laterobasal, frontobasal, and posterior basal fracture patterns are emphasized. CT often plays a complementary, supportive, or confirmatory role in management of skull base fractures in conjunction with results of physical examination, laboratory testing, and neurosensory evaluation. CT provides prognostic information about short- and long-term risk of cerebrospinal fluid (CSF) leak, encephalocele, meningitis, facial nerve paralysis, hearing and vision loss, cholesteatoma, vascular injuries, and various cranial nerve palsies and syndromes. The radiologist should leverage understanding of specific strengths and limitations of CT to anticipate next steps in the skull base fracture management plan. Additional imaging is warranted to clarify ambiguity (particularly for potential sources of CSF leak); in other cases, clinical and CT criteria alone are sufficient to determine the need for intervention and the choice of surgical approach. The radiologist should be able to envision stepping into a multidisciplinary planning discussion and engaging neurotologists, neuro-ophthalmologists, neurosurgeons, neurointerventionalists, and facial reconstructive surgeons to help synthesize an optimal management plan after reviewing the skull base CT findings at hand. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Osamu Sakai
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Kathryn Champ
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Dheeraj Gandhi
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Bizhan Aarabi
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Arthur J Nam
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - Robert E Morales
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
| | - David J Eisenman
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., K.C., D.G., R.E.M.), R. Adams Cowley Shock Trauma Center (D.D., B.A., A.J.N.), Department of Neurosurgery (B.A.), Division of Plastic Surgery (A.J.N.), and Department of Otorhinolaryngology-Head and Neck Surgery (D.J.E.), University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201; Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Mass (O.S.); and Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD (K.C.)
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Abstract
A host of different types of direct and indirect, primary and secondary injuries can affect different portions of the optic nerve(s). Thus, in the setting of penetrating as well as nonpenetrating head or facial trauma, a high index of suspicion should be maintained for the possibility of the presence of traumatic optic neuropathy (TON). TON is a clinical diagnosis, with imaging frequently adding clarification to the full nature/extent of the lesion(s) in question. Each pattern of injury carries its own unique prognosis and theoretical best treatment; however, the optimum management of patients with TON remains unclear. Indeed, further research is desperately needed to better understand TON. Observation, steroids, surgical measures, or a combination of these are current cornerstones of management, but statistically significant evidence supporting any particular approach for TON is absent in the literature. Nevertheless, it is likely that novel management strategies will emerge as more is understood about the converging pathways of various secondary and tertiary mechanisms of cell injury and death at play in TON. In the meantime, given our current deficiencies in knowledge regarding how to best manage TON, "primum non nocere" (first do no harm) is of utmost importance.
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Affiliation(s)
- Neil R Miller
- Department of Ophthalmology, Neurology & Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Le Roux MK, Thollon L, Godio-Raboutet Y, Carbonnel E, Guyot L, Graillon N, Foletti JM. The association of Le Fort midfacial fractures with frontobasal injuries: a 17-year review of 125 cases, reflections on biomechanics, classifications and treatment. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2020; 122:561-565. [PMID: 33035710 DOI: 10.1016/j.jormas.2020.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
The frequency of midface and frontobasal fractures has increased over the past 40 years despite the improvement and stringent regulation implemented on modern safety equipment (belts, helmets…). This observation might be correlated with the progress of radiodiagnosis tools. Literature was reviewed according to Prisma guidelines. We searched for reviewed articles, published between January 2000 and December 2017, through Medline (Pubmed) online databases and ScienceDirect, using the following MeSH Keywords: "Le Fort classification", "Le Fort fracture", "Frontobasal fracture", "skull base fracture", "Midface Fractures". Among 652 patients with frontobasal fractures, 125 (19.1%) were associated with a Le Fort fracture. 59 (9%) were associated with Le Fort III fracture, 51 (7.8%) with Le Fort II fracture and 15 (2.3%) with Le Fort I fracture. When frontobasal fractures were associated with midfacial fractures, we found 18 cerebrospinal fluid leaks (11.8 %) and 19 cases of meningitis (12.5 %). When only the frontobasal area was involved, there were 6 cerebrospinal fluid leaks (4.3 %) and 6 meningitis (4.3 %). Our results highlight a regular association between Le Fort fractures and frontobasal fractures for stages II and stage III of Le Fort fractures and also found a higher rate of neuro-septic complication. Further research shall investigate treatment and monitoring recommendations fitting modern epidemiology of craniofacial traumatology.
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Affiliation(s)
- Marc-Kevin Le Roux
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.
| | - Lionel Thollon
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | | | - Emeric Carbonnel
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | - Laurent Guyot
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France
| | - Nicolas Graillon
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France
| | - Jean-Marc Foletti
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
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Douglas J, Gill K, Holmes S. Combining trauma severity indices to create a unified craniofacial disruption index: addition of the frontobasal unit to the ZS model. Br J Oral Maxillofac Surg 2020; 58:784-788. [DOI: 10.1016/j.bjoms.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/02/2020] [Indexed: 11/25/2022]
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Pollock RA, Gossman M. Anatomical Revelations in 1921 Kindled Operative Repair of the Orbit, Eyelids, and Periorbit over the Ensuing 100 Years: The Diuturnity of Ernest Whitnall (1876–1950) of Oxford, Montreal, and Bristol. Craniomaxillofac Trauma Reconstr 2019; 12:95-107. [DOI: 10.1055/s-0039-1677696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022] Open
Abstract
Revelations of orbital, intraorbital, and periorbital anatomy by a single author in 1921 kindled attempts at operative repair of the orbit, eyelids, and periorbit over the ensuing 100 years. They are the lasting contributions—the diuturnity—of Samuel Ernest Whitnall (1876–1950) of Oxford, Montreal, and Bristol.
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Affiliation(s)
- Richard A. Pollock
- University of Pittsburg Medical Center Pinnacle Lancaster, Lancaster, Pennsylvania
- University of Pittsburg Medical Center Pinnacle Lititz, Lititz, Pennsylvania
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16
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Linear Frontal Bone Fractures - Clinical and Surgical Profile: A Retrospective Study. Trauma Mon 2016. [DOI: 10.5812/traumamon.41657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Stojanowski CM, Seidel AC, Fulginiti LC, Johnson KM, Buikstra JE. Contesting the massacre at Nataruk. Nature 2016; 539:E8-E10. [DOI: 10.1038/nature19778] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 08/09/2016] [Indexed: 11/09/2022]
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18
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Abstract
Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.
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Affiliation(s)
- Matthew Bobinski
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
| | - Peter Y Shen
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
| | - Arthur B Dublin
- Department of Radiology, University of California-Davis School of Medicine, Sacramento, California, United States
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19
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The effect of direction of force to the craniofacial skeleton on the severity of brain injury in patients with a fronto-basal fracture. Int J Oral Maxillofac Surg 2016; 45:872-7. [DOI: 10.1016/j.ijom.2016.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/17/2015] [Accepted: 01/26/2016] [Indexed: 11/24/2022]
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20
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Single-Stage Surgical Reconstruction of Posttraumatic Compound Complex Fronto-Basal Cranial Vault Fracture in a Resource-Limited Practice. J Craniofac Surg 2016; 27:1302-5. [DOI: 10.1097/scs.0000000000002791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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21
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Chegini S, Gallighan N, Mcleod N, Corkill R, Bojanic S, Griffiths S, Dhariwal D. Outcomes of treatment of fractures of the frontal sinus: review from a tertiary multispecialty craniofacial trauma service. Br J Oral Maxillofac Surg 2016; 54:801-5. [PMID: 27266977 DOI: 10.1016/j.bjoms.2016.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/15/2016] [Indexed: 11/29/2022]
Abstract
There are no agreed national guidelines for the treatment of fractures of the frontal sinus and the naso-orbitoethmoid complex. The Oxford University Hospitals Craniofacial Trauma unit was set up five years ago as a joint oral and maxillofacial, ENT, and neurosurgical service, and we present our experience to date in the treatment of patients with such fractures. The study includes 91 patients with data collected from a prospective database. Patients underwent cranialisation if they met the criteria of persistent leak of cerebrospinal fluid (CSF), displaced fracture of the posterior wall or obstruction of the nasofrontal outflow tract. The mean follow-up time was 42 months (range 1-10 years). Three groups of patients were analysed. Group 1 met the criteria for, and were treated by, cranialisation (n=50). Group 2 met the criteria for cranialisation, but were treated conservatively because of coexisting conditions (n=8). Group 3 did not match the criteria for treatment, and were managed conservatively (n=33). The numbers of patients with complications or who required further operation were: group 1 (4/50), group 2 (3/8), and group 3 (3/33). There were significantly fewer complications among those patients who met the operative criteria and were treated by cranialisation than among those treated conservatively (p=0.04). These outcomes from one dedicated multispecialist craniofacial trauma unit in the UK may help surgeons who care for patients with this specific group of injuries. Our morbidity was in keeping with published figures.
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Affiliation(s)
- Soudeh Chegini
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU.
| | - Niamh Gallighan
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
| | - Niall Mcleod
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
| | - Rufus Corkill
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
| | - Stana Bojanic
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
| | - Stewart Griffiths
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
| | - Daljit Dhariwal
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU
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Veeramuthu V, Hariri F, Narayanan V, Tan LK, Ramli N, Ganesan D. Microstructural Change and Cognitive Alteration in Maxillofacial Trauma and Mild Traumatic Brain Injury: A Diffusion Tensor Imaging Study. J Oral Maxillofac Surg 2016; 74:1197.e1-1197.e10. [DOI: 10.1016/j.joms.2016.01.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 01/14/2023]
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Stephens JR, Holmes S, Evans BT. Applied anatomy of the anterior cranial fossa: what can fracture patterns tell us? Int J Oral Maxillofac Surg 2015; 45:275-8. [PMID: 26589135 DOI: 10.1016/j.ijom.2015.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
The skull base is uniquely placed to absorb anteriorly directed forces imparted either via the midfacial skeleton or cranial vault. A variety of skull base fracture classifications exist. Less well understood, however, is fracture extension beyond the anterior cranial fossa (ACF) into the middle and posterior cranial fossae. The cases of 81 patients from two UK major trauma centres were studied to examine the distribution of fractures across the skull base and any relationship between the vector of force and extent of skull base injury. It was found that predominantly lateral force to the craniofacial skeleton produced a fracture that propagated beyond the ACF into the middle cranial fossa in 77.4% of cases, significantly more (P<0.001) than for predominantly anterior force (12.0%). Fractures were significantly more likely to propagate into the posterior fossa with a lateral vector of impact compared to an anterior vector (P=0.049). This difference in energy transfer across the skull base may, in part, be explained by the local anatomy. The more delicate central ACF acts as a 'crumple zone' in order to absorb force. Conversely, no collapsible interface exists in the lateral aspect of the ACF, thus the lateral ACF behaves like a 'buttress', resulting in increased energy transfer.
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Affiliation(s)
- J R Stephens
- The Craniofacial Trauma Research Group, Queen Mary University London, London, UK; Faculty of Medicine, University of Southampton, University Hospital Southampton, Southampton, UK.
| | - S Holmes
- The Craniofacial Trauma Research Group, Queen Mary University London, London, UK; Department of Oral and Maxillofacial Surgery, The Royal London Hospital, Whitechapel, London, UK
| | - B T Evans
- The Craniofacial Trauma Research Group, Queen Mary University London, London, UK; Department of Oral and Maxillofacial Surgery, University Hospital Southampton, Southampton, UK
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Garg RK, Afifi AM, Gassner J, Hartman MJ, Leverson G, King TW, Bentz ML, Gentry LR. A novel classification of frontal bone fractures: The prognostic significance of vertical fracture trajectory and skull base extension. J Plast Reconstr Aesthet Surg 2015; 68:645-53. [PMID: 25778872 DOI: 10.1016/j.bjps.2015.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/25/2015] [Accepted: 02/02/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The broad spectrum of frontal bone fractures, including those with orbital and skull base extension, is poorly understood. We propose a novel classification scheme for frontal bone fractures. METHODS Maxillofacial CT scans of trauma patients were reviewed over a five year period, and frontal bone fractures were classified: Type 1: Frontal sinus fracture without vertical extension. Type 2: Vertical fracture through the orbit without frontal sinus involvement. Type 3: Vertical fracture through the frontal sinus without orbit involvement. Type 4: Vertical fracture through the frontal sinus and ipsilateral orbit. Type 5: Vertical fracture through the frontal sinus and contralateral or bilateral orbits. We also identified the depth of skull base extension, and performed a chart review to identify associated complications. RESULTS 149 frontal bone fractures, including 51 non-vertical frontal sinus (Type 1, 34.2%) and 98 vertical (Types 2-5, 65.8%) fractures were identified. Vertical fractures penetrated the middle or posterior cranial fossa significantly more often than non-vertical fractures (62.2 v. 15.7%, p = 0.0001) and had a significantly higher mortality rate (18.4 v. 0%, p < 0.05). Vertical fractures with frontal sinus and orbital extension, and fractures that penetrated the middle or posterior cranial fossa had the strongest association with intracranial injuries, optic neuropathy, disability, and death (p < 0.05). CONCLUSIONS Vertical frontal bone fractures carry a worse prognosis than frontal bone fractures without a vertical pattern. In addition, vertical fractures with extension into the frontal sinus and orbit, or with extension into the middle or posterior cranial fossa have the highest complication rate and mortality.
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Affiliation(s)
- Ravi K Garg
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Ahmed M Afifi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA; Division of Plastic Surgery, Cairo University, Cairo, Egypt.
| | - Jennifer Gassner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Michael J Hartman
- Section of Head and Neck Imaging, Department of Radiology, University of Wisconsin, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Timothy W King
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Michael L Bentz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Lindell R Gentry
- Section of Head and Neck Imaging, Department of Radiology, University of Wisconsin, Madison, WI, USA
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25
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Awadalla AM, Emara S, Elkammash T, Nablsi H, Sief K. Immediate single-stage reconstruction of complex frontofaciobasal injuries: Part II. Br J Neurosurg 2015; 29:419-24. [PMID: 25686654 DOI: 10.3109/02688697.2015.1006169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The purpose of this prospective study was to identify selection criteria for immediate single-stage reconstruction in patients with severe complex craniofacial trauma to improve their functional outcome and reduce complications. PATIENTS AND METHODS In this series, 24 new patients (16 men and 8 women) were added to our previous group (26 patients) with an age range from 10 to 55 years with mean of 26 years and Glasgow Coma Scale scores of 5-13; all patients had a combined single-stage repair of their complex craniofacial injuries within 6 h of their admission. We added some modifications to our standard technique using three-dimensional computed tomography, intracranial pressure monitoring, and support of dural repair/graft using dural patch and glue. The esthetic facial outcome was evaluated by an independent plastic assessor based on objective scale criteria. This series was carried out in Prince Salman Military Hospital between November 2010 and September 2013. RESULTS Early neurosurgical outcome was considered good in 22/24 patients (92%), moderate in one patient (4%), and poor in the last one (4%). At late evaluation, 20 cases (83%) regained their consciousness without any cognitive deficit. One patient (4%) remained in neurovegetative status. Early esthetic outcome was considered to be excellent in 18/24 patients (75%), good in 3 patients (12.5%), deemed fair in 2 patients (8%), and labeled poor in only 1 patient (4%). At late evaluation, the patient labeled fair had improved to good with topical scar management and the patient deemed poor had improved to fair with two successive plastic procedures. Complications included a cerebrospinal fluid leak in 2 patients (8%), one was managed conservatively and the second was treated surgically with intra- and extradural grafting. CONCLUSION In complex frontofaciobasal injuries, successful facial repair depends on immediate and definitive reconstruction. However, improved neurological outcomes in these patients depend on judicious selection of the appropriate candidates from severely head-injured patients.
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Affiliation(s)
- Akram M Awadalla
- Department of Neurosurgery, School of Medicine, Zagazig University, Egypt and Prince Salman Military Hospital , Tabouk , Saudi Arabia
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26
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Connon FV, Austin SJB, Nastri AL. Orbital Roof Fractures: A Clinically Based Classification and Treatment Algorithm. Craniomaxillofac Trauma Reconstr 2014; 8:198-204. [PMID: 26269727 DOI: 10.1055/s-0034-1393728] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 05/03/2014] [Indexed: 10/24/2022] Open
Abstract
Orbital roof fractures are relatively uncommon in craniofacial surgery but present a management challenge due to their anatomy and potential associated injuries. Currently, neither a classification system nor treatment algorithm exists for orbital roof fractures, which this article aims to provide. This article provides a literature review and clinical experience of a tertiary trauma center in Australia. All cases admitted to the Royal Melbourne Hospital with orbital roof fractures between January 2011 and July 2013 were reviewed regarding patient characteristics, mechanism, imaging (computed tomography), and management. Forty-seven patients with orbital roof fractures were treated. Three of these were isolated cases. Forty were male and seven were female. Assault (14) and falls (13) were the most common causes of injury. Forty-two patients were treated conservatively and five had orbital roof repairs. On the basis of the literature and local experience, we propose a four-point system, with subcategories allowing for different fracture characteristics to impact management. Despite the infrequency of orbital roof fractures, their potential ophthalmological, neurological, and functional sequelae can carry a significant morbidity. As such, an algorithm for management of orbital roof fractures may help to ensure appropriate and successful management of these patients.
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Affiliation(s)
- Felicity Victoria Connon
- Department of Oral and Maxillofacial Surgery, Royal Melbourne Hospital, Parkville, Australia ; Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Parkville, Australia
| | - S J B Austin
- Department of Oral and Maxillofacial Surgery, Royal Melbourne Hospital, Parkville, Australia
| | - A L Nastri
- Department of Oral and Maxillofacial Surgery, Royal Melbourne Hospital, Parkville, Australia
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Audigé L, Cornelius CP, Di Ieva A, Prein J. The First AO Classification System for Fractures of the Craniomaxillofacial Skeleton: Rationale, Methodological Background, Developmental Process, and Objectives. Craniomaxillofac Trauma Reconstr 2014; 7:S006-14. [PMID: 25489387 DOI: 10.1055/s-0034-1389556] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Validated trauma classification systems are the sole means to provide the basis for reliable documentation and evaluation of patient care, which will open the gateway to evidence-based procedures and healthcare in the coming years. With the support of AO Investigation and Documentation, a classification group was established to develop and evaluate a comprehensive classification system for craniomaxillofacial (CMF) fractures. Blueprints for fracture classification in the major constituents of the human skull were drafted and then evaluated by a multispecialty group of experienced CMF surgeons and a radiologist in a structured process during iterative agreement sessions. At each session, surgeons independently classified the radiological imaging of up to 150 consecutive cases with CMF fractures. During subsequent review meetings, all discrepancies in the classification outcome were critically appraised for clarification and improvement until consensus was reached. The resulting CMF classification system is structured in a hierarchical fashion with three levels of increasing complexity. The most elementary level 1 simply distinguishes four fracture locations within the skull: mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). Levels 2 and 3 focus on further defining the fracture locations and for fracture morphology, achieving an almost individual mapping of the fracture pattern. This introductory article describes the rationale for the comprehensive AO CMF classification system, discusses the methodological framework, and provides insight into the experiences and interactions during the evaluation process within the core groups. The details of this system in terms of anatomy and levels are presented in a series of focused tutorials illustrated with case examples in this special issue of the Journal.
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Affiliation(s)
- Laurent Audigé
- AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland ; Research and Development Department, Schulthess Clinic, Zürich, Switzerland
| | - Carl-Peter Cornelius
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians Universität München, Germany
| | - Antonio Di Ieva
- Department of Systematic Anatomy and Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Joachim Prein
- Clinic for Oral and Craniomaxillofacial Surgery, University Hospital Basel, Basel, Switzerland
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Cornelius CP, Audigé L, Kunz C, Buitrago-Téllez CH, Rudderman R, Prein J. The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial. Craniomaxillofac Trauma Reconstr 2014; 7:S068-91. [PMID: 25489392 DOI: 10.1055/s-0034-1389561] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
This tutorial outlines the details of the AOCMF image-based classification system for fractures of the midface at the precision level 3. The topography of the different midface regions (central midface-upper central midface, intermediate central midface, lower central midface-incorporating the naso-orbito-ethmoid region; lateral midface-zygoma and zygomatic arch, palate) is subdivided in much greater detail than in level 2 going beyond the Le Fort fracture types and its analogs. The level 3 midface classification system is presented along with guidelines to precisely delineate the fracture patterns in these specific subregions. It is easy to plot common fracture entities, such as nasal and naso-orbito-ethmoid, and their variants due to the refined structural layout of the subregions. As a key attribute, this focused approach permits to document the occurrence of fragmentation (i.e., single vs. multiple fracture lines), displacement, and bone loss. Moreover, the preinjury dental state and the degree of alveolar atrophy in edentulous maxillary regions can be recorded. On the basis of these individual features, tooth injuries, periodontal trauma, and fracture involvement of the alveolar process can be assessed. Coding rules are given to set up a distinctive formula for typical midface fractures and their combinations. The instructions and illustrations are elucidated by a series of radiographic imaging examples. A critical appraisal of the design of this level 3 midface classification is made.
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Affiliation(s)
- Carl-Peter Cornelius
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilians Universität München, Germany
| | - Laurent Audigé
- AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland ; Research and Development Department, Schulthess Clinic, Zürich, Switzerland
| | - Christoph Kunz
- Clinic for Oral and Craniomaxillofacial Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Randal Rudderman
- Plastic, Reconstruction & Maxillofacial Surgery, Alpharetta, Georgia
| | - Joachim Prein
- Clinic for Oral and Craniomaxillofacial Surgery, University Hospital Basel, Basel, Switzerland
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Ieva AD, Audigé L, Kellman RM, Shumrick KA, Ringl H, Prein J, Matula C. The Comprehensive AOCMF Classification: Skull Base and Cranial Vault Fractures - Level 2 and 3 Tutorial. Craniomaxillofac Trauma Reconstr 2014; 7:S103-13. [PMID: 25489394 PMCID: PMC4251721 DOI: 10.1055/s-0034-1389563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial classification system with increasing level of complexity and details. The highest level 1 system distinguish four major anatomical units, including the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). This tutorial presents the level 2 and more detailed level 3 systems for the skull base and cranial vault units. The level 2 system describes fracture location outlining the topographic boundaries of the anatomic regions, considering in particular the endocranial and exocranial skull base surfaces. The endocranial skull base is divided into nine regions; a central skull base adjoining a left and right side are divided into the anterior, middle, and posterior skull base. The exocranial skull base surface and cranial vault are divided in regions defined by the names of the bones involved: frontal, parietal, temporal, sphenoid, and occipital bones. The level 3 system allows assessing fracture morphology described by the presence of fracture fragmentation, displacement, and bone loss. A documentation of associated intracranial diagnostic features is proposed. This tutorial is organized in a sequence of sections dealing with the description of the classification system with illustrations of the topographical skull base and cranial vault regions along with rules for fracture location and coding, a series of case examples with clinical imaging and a general discussion on the design of this classification.
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Affiliation(s)
- Antonio Di Ieva
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Laurent Audigé
- AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland
- Research and Development Department, Schulthess Clinic, Zürich, Switzerland
| | - Robert M. Kellman
- Department of Otolarynology-Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, New York
| | | | - Helmut Ringl
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Joachim Prein
- Clinic for Oral and Craniomaxillofacial Surgery, University Hospital Basel, Basel, Switzerland
| | - Christian Matula
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Awadalla AM, Ezzeddine H, Fawzy N, Saeed MA, Ahmad MR. Immediate single-stage reconstruction of complex frontofaciobasal injuries: part I. J Neurol Surg B Skull Base 2014; 76:108-16. [PMID: 25844296 DOI: 10.1055/s-0034-1389371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 06/13/2014] [Indexed: 10/24/2022] Open
Abstract
Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.
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Affiliation(s)
- Akram Mohamed Awadalla
- Department of Neurosurgery, Zagazig University, Zagazig, Sharkia Ap-125, Egypt ; Department of Neurosurgery, King Abdl-Azizi Specialist Hospital, Taif, Saudi Arabia
| | - Hichem Ezzeddine
- Department of Faciomaxillary, King Abdl-Aziz specialist center-KSA, Taif, Saudi Arabia
| | - Naglaaa Fawzy
- Department of Radiodiagnosis, King Abdl-Aziz specialist center-KSA, Taif, Saudi Arabia
| | - Mohammad Al Saeed
- Department of General Surgery, Trauma Unit, King Abdl-Aziz Specialist Center, Taif, Saudi Arabia
| | - Mohammad R Ahmad
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, Zagazig University, Zagazig, Sharkia Ap-130, Egypt
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Monnazzi M, Gabrielli M, Pereira-Filho V, Hochuli-Vieira E, de Oliveira H, Gabrielli M. Frontal sinus obliteration with iliac crest bone grafts. Review of 8 cases. Craniomaxillofac Trauma Reconstr 2014; 7:263-70. [PMID: 25383146 DOI: 10.1055/s-0034-1382776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 03/04/2013] [Indexed: 10/25/2022] Open
Abstract
UNLABELLED This study evaluated postoperative results of 8 cases of frontal sinus fractures treated by frontal sinus obliteration with autogenous bone from the anterior iliac crest. PATIENTS AND METHODS The medical charts of patients sequentially treated for frontal sinus fractures by obliteration with autogenous cancellous iliac crest bone in the Oral and Maxillofacial Surgery Division of this institution were reviewed. From those, eight had complete records and adequately described long-term follow-up. All were operated by the same surgical team. Those patients were recalled and independently evaluated by 2 examiners. Radiographs and/or CT scans were available for this evaluation. Associated fractures and complications were noted. The average postoperative follow-up was 7 years, ranging from 3 to 16 years. The main complication was infection. Four patients (50%) had uneventful long-term follow-ups and four (50%) experienced complications requiring reoperation. Based on the studied sample studied the authors conclude that the obliteration with autogenous bone presented a high percentage of complications in this series.
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Affiliation(s)
- Marcelo Monnazzi
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
| | - Marisa Gabrielli
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
| | - Valfrido Pereira-Filho
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
| | - Eduardo Hochuli-Vieira
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
| | - Henrique de Oliveira
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
| | - Mario Gabrielli
- Department of Diagnosis and Oral and Maxillofacial Surgery, Dental School of Araraquara (UNESP)
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Perheentupa U, Mäkitie AA, Kinnunen I. Subcranial craniotomy approach for frontobasal fracture correction. J Craniomaxillofac Surg 2014; 42:1371-7. [PMID: 24780354 DOI: 10.1016/j.jcms.2014.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 02/12/2014] [Accepted: 03/25/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Frontobasilar fracture types and the outcome of patients after management with the subcranial approach technique were evaluated. MATERIAL AND METHODS A retrospective analysis of 48 patients (45 males, mean age 38,5 years; range 16-82 years) who had a subcranial approach for frontal base fracture correction between April 1996 and April 2011 at a tertiary care academic hospital in Turku, Finland. RESULTS Sixteen (33%) patients had fractures including all frontobasilar fracture types (Type I-IV) i.e. fractures that involved frontal sinuses, orbital roofs, ethmoidal region, cribriform plate and sphenoidal region. Twenty-seven (56%) patients were considered to have had brain damage at presentation. Forty percent of patients were suffering from synchronous trauma. Peroperatively, 31 (65%) patients had exposure or defect of the dura due to bone dehiscence but only two patients suffered from cerebrospinal fluid (CSF) fistula following surgery. CSF fistulae were covered by pericranium in most of the cases (68%). There was no postoperative meningitis. Thirty-eight percent of the patients needed further operation with a subcranial craniotomy following primary reconstruction. At the last follow-up visit 35% were suffering from permanent neurological problems following brain injury. CONCLUSIONS Subcranial approach seemed successful in the management of all frontobasilar fractures in this series with reasonably low complication rate. Therefore, we would recommend it as the technique of choice in multiple and even in the most complicated frontal base fractures.
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Affiliation(s)
- Ulla Perheentupa
- Department of Otolaryngology - Head and Neck Surgery (Head: Professor Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI - 20521 Turku, Finland.
| | - Antti A Mäkitie
- Department of Otolaryngology - Head and Neck Surgery, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Ilpo Kinnunen
- Department of Otolaryngology - Head and Neck Surgery (Head: Professor Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI - 20521 Turku, Finland
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Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007): review and update of a compelling procedure in the selected patient. Ann Plast Surg 2014; 71:54-9. [PMID: 22918401 DOI: 10.1097/sap.0b013e3182468198] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.
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Facial Fractures of the Upper Craniofacial Skeleton Predict Mortality and Occult Intracranial Injury After Blunt Trauma. J Craniofac Surg 2013; 24:1922-6. [DOI: 10.1097/scs.0b013e3182a30544] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Piccirilli M, Anichini G, Cassoni A, Ramieri V, Valentini V, Santoro A. Anterior cranial fossa traumas: clinical value, surgical indications, and results-a retrospective study on a series of 223 patients. J Neurol Surg B Skull Base 2013; 73:265-72. [PMID: 23905003 DOI: 10.1055/s-0032-1312715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 12/07/2011] [Indexed: 10/28/2022] Open
Abstract
Objective Frontobasal fractures are relatively common traumas but surgical indications are still discussed. The authors report their results on patients showing anterior cranial fossa fractures; clinical data, surgical indications, and results are reported and critically analyzed. Methods From 1991 to 2010, 223 patients were admitted in our institution with diagnosis of anterior cranial fossa fracture. Fractures were classified as type A-fracture of the anterior wall of the frontal sinus; type B-fracture of the posterior wall of the frontal sinus; and type C-frontobasal traumas without involvement of the frontal sinus. All patients entered a follow-up program consisting in periodic controls. Results A total of 105 patients were conservatively treated, while 118 patients underwent surgical intervention. The presence of pneumocephalus (p < 0.0001) and rhinoliquorrhea (p = 0.001) were the factors influencing the surgical indication. In the fractures of group B with signs of pneumocephalus and or rhinoliquorrhea, full sinus cranialization represents the variable mainly influencing the outcome (p < 0.001). Conclusion Patients with frontobasal traumas should be carefully evaluated to choose the best treatment option. Clinical and radiological data suggest that patients with frontobasal fractures with massive pneumocephalus and/or rhinoliquorrhea should be always surgically treated.
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Affiliation(s)
- Manolo Piccirilli
- Department of Neurological Science, Neurosurgery, University of Rome "Sapienza," Rome, Italy
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Sphenoid sinus and sphenoid bone fractures in patients with craniomaxillofacial trauma. Craniomaxillofac Trauma Reconstr 2013; 6:179-86. [PMID: 24436756 DOI: 10.1055/s-0033-1343778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 08/25/2012] [Indexed: 10/26/2022] Open
Abstract
Background and Purpose Sphenoid bone fractures and sphenoid sinus fractures have a high morbidity due to its association with high-energy trauma. The purpose of this study is to describe individuals with traumatic injuries from different mechanisms and attempt to determine if there is any relationship between various isolated or combined fractures of facial skeleton and sphenoid bone and sphenoid sinus fractures. Methods We retrospectively studied hospital charts of all patients who reported to the trauma center at Hospital de San José with facial fractures from December 2009 to August 2011. All patients were evaluated by computed tomography scan and classified into low-, medium-, and high-energy trauma fractures, according to the classification described by Manson. Design This is a retrospective descriptive study. Results The study data were collected as part of retrospective analysis. A total of 250 patients reported to the trauma center of the study hospital with facial trauma. Thirty-eight patients were excluded. A total of 212 patients had facial fractures; 33 had a combination of sphenoid sinus and sphenoid bone fractures, and facial fractures were identified within this group (15.5%). Gender predilection was seen to favor males (77.3%) more than females (22.7%). The mean age of the patients was 37 years. Orbital fractures (78.8%) and maxillary fractures (57.5%) were found more commonly associated with sphenoid sinus and sphenoid bone fractures. Conclusions High-energy trauma is more frequently associated with sphenoid fractures when compared with medium- and low-energy trauma. There is a correlation between facial fractures and sphenoid sinus and sphenoid bone fractures. A more exhaustive multicentric case-control study with a larger sample and additional parameters will be essential to reach definite conclusions regarding the spectrum of fractures of the sphenoid bone associated with facial fractures.
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Sung EK, Nadgir RN, Sakai O. Computed tomographic imaging in head and neck trauma: what the radiologist needs to know. Semin Roentgenol 2013; 47:320-9. [PMID: 22929691 DOI: 10.1053/j.ro.2012.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Edward K Sung
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
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A management algorithm for cerebrospinal fluid leak associated with anterior skull base fractures: detailed clinical and radiological follow-up. Neurosurg Rev 2011; 35:227-37; discussion 237-8. [DOI: 10.1007/s10143-011-0352-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 05/03/2011] [Accepted: 05/15/2011] [Indexed: 10/17/2022]
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Gelesko S, Bell R, Dierks E, Potter B. Subcranial Navigation-Assisted Repair of Frontobasal Skull Fractures. J Oral Maxillofac Surg 2011. [DOI: 10.1016/j.joms.2011.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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