Epidemiological survey of head and neck injuries and trauma in the United States

Differences in Cervical Spine Fractures in Patients Younger or Older Than 65 Years of Age: Implications for the Canadian C-Spine Rule

BACKGROUND AND PURPOSE

There has been a distinction made in the 2001 Canadian C-Spine Rule regarding patients 65 and older and younger than 65 years of age as far as indications for cervical spine CT scanning. We sought to determine if there are differences in the symptoms, mechanisms of injury, fracture locations, and types that are still relevant in 2024.

MATERIALS AND METHODS

The institutional review board approved this retrospective study of cervical spine CT emergency department results from 2 hospitals in our health system after reviewing 5 years of data in patients experiencing trauma. In addition to the primary variable of age (younger than 65 years and 65 years and older), we looked at injury mechanism, fracture types, sites, symptoms, and operative or medical treatments. Because the demographics of our home site is different from most towns in the United States, we provide race/ethnicity data.

RESULTS

Of 21,986 cervical spine CTs, 190/9455 (2.0%) participants 65 years of age and older and 199/12,531 (1.6%) participants younger than 65 years of age had fractures (total, 389/21,986, 1.8%). There were more cases of falls from standing (106, 55.8%) and falls from a height (46, 4.2%) in those 65 years and older and this mechanism was associated with a higher risk of C1 and C2 fractures (52, 27.4%; and 78, 41.1%, respectively). Among the C1 fractures, anterior and posterior arch fractures predominated (37, 19.5%). For C2 fractures, types 2 and 3 odontoid fractures (39, 20.5%; and 12, 6.3%) were more common in the older cohort. Motor vehicle collisions were more common in the younger cohort (89, 44.7%), and they were associated with more C5-C7 fractures (47, 23.6%; 60, 30.2%; and 66, 33.2%, respectively) including the facets (49, 24.6%), spinous processes (31, 15.6%), and transverse processes (52, 26.1%). Overall, the rates of instability, surgical intervention, and asymptomatic fractures were similar in the 2 age groups.

CONCLUSIONS

Cervical spine fractures appear in about 1.8% of the CT scans performed in a busy emergency department environment. Fractures in the elderly occur more commonly due to falls, are located at C1 and C2, and may involve ligamentous injuries. Younger patients incur trauma more commonly due to motor vehicle collisions, and they are more likely to affect the posterior elements, especially C5-C7. The differences in trends for fractures in the 65 years of age and older and younger than 65 years of age groups have persisted since the Canadian C-Spine Rule 1996-1998 data were collected.

Sex differences in the epidemiology of spontaneous and traumatic cervical artery dissections

BACKGROUND

Recent studies show cervical artery dissection (CeAD) is equally common between sexes, and that the incidence of CeAD has risen at a greater rate in females than males. In this population-based study, we identify sex differences in patients diagnosed with spontaneous and traumatic CeAD.

METHODS

144 patients with spontaneous or traumatic CeAD were studied for sex differences in medical comorbidities, presenting symptoms and outcomes.

RESULTS

Females were more likely to carry a diagnosis of migraine, while males were more likely to have hyperlipidaemia. Females were more likely to present with neck pain, males with stroke. Females were significantly more likely to develop recurrent dissections in the study period.

CONCLUSIONS

These findings underscore the importance of understanding CeAD through the lens of sex differences and may explain the significant rise in the diagnosis of CeAD in females. These findings support the importance of considering sex-specific risk factors and medical comorbidities with sex predilection in the diagnosis and management of CeAD. Furthermore, it emphasises the importance of female patients understanding risk factors and presenting signs that should prompt evaluation for CeAD.

Randomised controlled trial of resorbable versus non-resorbable sutures for lacerations of the face (TORN Face)

Facial lacerations are commonly encountered in emergency departments and require effective management to optimise aesthetic outcomes. Non-resorbable sutures are traditionally favoured for their tensile strength and minimal inflammatory response, despite the inconvenience of the required follow up for removal. This single-centre, single-blinded randomised controlled trial aimed to compare the clinical efficacy and cost-effectiveness of resorbable (Vicryl Rapide) versus non-resorbable (Ethilon) sutures for the closure of facial lacerations in adults. Between November 2021 and February 2023, 200 adult patients presenting with facial lacerations were randomly allocated to either resorbable or non-resorbable sutures. Outcomes assessed included aesthetic results via the Visual Analogue Scale (VAS) and Hamilton Scar Scale, patient-reported satisfaction using the Patient Scar Assessment Questionnaire (PSAQ), complication rates, and cost analysis. No significant differences were found in mean VAS scores between the two groups in both modified intention-to-treat and per-protocol analyses. The majority of patients reported high satisfaction levels. Early complication rates were significantly higher in the non-resorbable group at the one-week follow up, with no long-term differences noted. Preliminary cost analysis indicated a more than five-fold cost saving with resorbable sutures. Resorbable sutures provide a viable and cost-effective alternative to non-resorbable sutures for adult facial lacerations, with comparable aesthetic outcomes and patient satisfaction. Their use could reduce healthcare burdens by eliminating the need for follow-up suture removal, supporting broader adoption in clinical practice.

Systemic Outcomes in Adults Undergoing Emergent Repair of Orbital Blowout Fractures

Purpose

To analyze the association between emergent surgery status and systemic adverse outcomes in patients undergoing open orbital floor blowout fracture repair.

Methods

This retrospective cohort analysis utilized the 2005-2018 National Surgery Quality Improvement Program (NSQIP) database. Current Procedural Terminology (CPT) codes were used to identify cases with open treatment of orbital floor blowout fractures (21385, 21386, 21387, 21390, 21395). Demographics, comorbidities, and complication incidences were compared between patients undergoing emergent surgery and those undergoing non-emergent orbital blowout fracture repair using chi-square analyses. The independent effect of preoperative emergent status on adverse outcomes was analyzed using binary logistic regression.

Results

1,146 (96.0%) non-emergent and 48 (4.0%) emergent orbital blowout fracture repairs were identified from 2005 to 2018. Chi-square analysis indicated patients undergoing emergent repairs had higher incidences of preoperative wound infection (8.3% vs. 2.3%; p = 0.029) and systemic sepsis (8.3% vs. 0.6%; p = 0.001). The emergent cohort had a higher proportion of patients with Hispanic ethnicity (p = 0.011). Unadjusted chi-square analysis indicated the emergent cohort had a higher incidence of prolonged length of stay (50.1% vs. 10.1%; p < 0.001). After adjusting for confounders, logistic regression analysis indicated emergent status was an independent risk factor for prolonged length of stay (OR 13.05; 95% CI 5.26-32.37; p < 0.001).

Conclusion

Emergent surgery status is an important factor associated with increased odds of prolonged length of stay in patients undergoing open orbital blowout fracture repair.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04681-0.

Shifting Perspectives: Equal Blunt Cerebrovascular Risk in Low-Versus High-Energy Cervical Fracture

INTRODUCTION

Clinical implications of screening for blunt cerebrovascular injury (BCVI) after low-energy mechanisms of injury (LEMI) remain unclear. We assessed BCVI incidence and outcomes in LEMI versus high-energy mechanisms of injury (HEMI) patients.

METHODS

In this retrospective cohort study, blunt trauma adults admitted between July 2015 and June 2021 with cervical spine fractures, excluding single spinous process, osteophyte, and chronic fractures were included. Demographics, comorbidities, injuries, screening and treatment data, iatrogenic complications, and mortality were collected. Our primary end point was to compare BCVI rates between LEMI and HEMI patients.

RESULTS

Eight hundred sixty patients (78%) were screened for BCVI; 120 were positive for BCVI. LEMI and HEMI groups presented similar BCVI rates (12.6% versus 14.4%; P = 0.640). Compared to HEMI patients (n = 95), LEMI patients (n = 25) were significantly older (79 ± 14.9 versus 54.3 ± 17.4, P < 0.001), more likely to be on anticoagulants before admission (64% versus 23.2%, P < 0.001), and less severely injured (LEMI injury severity score 10.9 ± 6.6 versus HEMI injury severity score 18.7 ± 11.4, P = 0.001). All but one LEMI and 90.5% of the HEMI patients had vertebral artery injuries with no significant difference in BCVI grades. One HEMI patient developed acute kidney injury because of BCVI screening. Eleven HEMI patients developed BCVI-related stroke with two related mortalities. One LEMI patient died of a BCVI-related stroke.

CONCLUSIONS

BCVI rates were similar between HEMI and LEMI groups when screening based on cervical spine fractures. The LEMI group exhibited no screening or treatment complications, suggesting that benefits may outweigh the risks of screening and potential bleeding complications from treatment.

Pediatric head and neck trauma in the United States: Trends, risk factors and outcomes using the National Trauma Data Bank

Introduction

Pediatric head and neck (HN) trauma is an important contributor to pediatric morbidity, resulting in significant downstream consequences. Few studies provide epidemiological predictors of pediatric HN trauma on a national scale. The present study aims to identify risk factors of HN injury and mortality in the pediatric population.

Methods

A retrospective cohort study was conducted for patients (age <18 years) using the US National Trauma Data Bank (NTDB 2007-2019). Demographic, injury, and physiologic outcome data were analyzed. HN injury was defined as a head or neck Abbreviated Injury Scale (AIS) >0. Logistic regression identified independent predictors of mortality following HN trauma.

Results

Of the 1.42 million pediatric patients analyzed, 44.05% had HN injury. In patients aged 0-4, the most common mechanism was falls (47.67% in this age group) while in ages 14-17, motor vehicle/transport accidents (MVTs) were the most common mechanism (56.06%). Controlling for demographics, comorbidities, and injury severity, HN injury was associated with increased odds of mortality (OR 2.404, 95% CI 1.530-3.778). HN injury mortality was strongly predicted by firearm exposure (OR 11.28, 95% CI 6.074-20.95), age <4 (OR 1.179, 95% CI 1.071-1.299), and self-insured status (OR 1.977, 95% CI 1.811-2.157).

Conclusion

NTDB data demonstrate that the percentage of pediatric patients with HN trauma has decreased over the past 12 years although is associated with increased odds of mortality. Age and insurance status predicted mortality from HN trauma, with falls and MVTs being the most common mechanisms of injury. These data have implications for future public health efforts in this patient population.

Level of Evidence

3.

Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes

Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.

Management of Traumatic Nasal Avulsion Injuries

Soft tissue injuries to the midface (and nose) are common causes for seeking trauma care. As trauma patients, observing advanced trauma life support protocols is warranted given the risk of concomitant injuries. Here, options for optimizing tissue preservation, microvascular replantation, non-microvascular tissue replacement, and wound stabilization are discussed. Included in this discussion are data-driven predictors for successful replantation as well as technique descriptions with anatomic references to guide surgeons in choosing optimal donor vessels. In both partial and complete avulsion injuries, venous congestion is common. Several postoperative wound care protocols to maximize tissue perfusion and long-term viability are discussed.

Endovascular Embolization of Traumatic Vessel Injury Using N-butyl Cyanoacrylate: A Case Series

There is limited evidence of N-butyl cyanoacrylate (n-BCA) use in endovascular embolization of traumatic face and neck vessel injuries. We investigated the safety and effectiveness of n-BCA for this purpose. We retrospectively analyzed consecutive patients presenting to a Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years old with any vessel injury in the face and neck circulation requiring n-BCA embolization. The primary endpoint was n-BCA effectiveness defined as immediate control of active bleeding post-embolization. In total, 13 patients met the inclusion criteria. The median decade of life was 3 (IQR 3 - 5) with a male predominance (n = 11, 84.6%). Median Glasgow Coma Scale score on presentation was 15 (IQR 3-15). Eleven patients suffered gunshot wound injuries; two patients suffered blunt injuries. Injured vessels included facial artery (n = 6, 46.2%), buccal branch artery (n = 3, 23.1%), internal maxillary (n = 5, 38.5%), cervical internal carotid artery (n = 1, 7.7%), and vertebral artery (n = 1, 7.7%). All patients were treated with 1:2 n-BCA to ethiodol mixture with immediate extravasation control. No bleeding recurrence or need for retreatment occurred. One patient died in-hospital (7.7%). Patients were discharged to home (n = 8, 61.5%), day rehabilitation (n = 1, 7.7%), or acute rehabilitation (n = 3, 23.1%). One patient developed a right posterior cerebral artery infarct with hemorrhagic transformation. To our knowledge, this is the first study demonstrating the safety and effectiveness of n-BCA liquid embolism in traumatic vessel injuries, especially penetrating gunshot wounds.

Laryngeal Trauma

Laryngeal trauma is rare but potentially fatal. Initial evaluation includes efficient history and physical examination, imaging, bedside flexible laryngoscopy, and if necessary, operative endoscopic evaluation. Multiple classification systems exist for laryngeal trauma, and each has its merits. We recommend a patient-centered approach, rather than using the classification alone. Secure airways are the primary goal of acute management, with awake tracheostomy more often indicated over oral intubation compared with traumas not involving the larynx. More severe injuries typically require surgical intervention. Early intervention results in optimal voice and airway outcomes.

A Ten-Year Retrospective Cohort Study on Neck Collar Immobilization in Trauma Patients with Head and Neck Injuries

Background and Objectives: In the context of prehospital care, spinal immobilization is commonly employed to maintain cervical stability in head and neck injury patients. However, its use in cases of unclear consciousness or major trauma patients is often precautionary, pending the exclusion of unstable spinal injuries through appropriate diagnostic imaging. The impact of prehospital C-spinal immobilization in these specific patient populations remains uncertain. Materials and Methods: We conducted a retrospective cohort study at Taipei Tzu Chi Hospital from January 2009 to May 2019, focusing on trauma patients suspected of head and neck injuries. The primary outcome assessed was in-hospital mortality. We employed multivariable logistic regression to investigate the relationship between prehospital C-spine immobilization and outcomes, while adjusting for various factors such as age, gender, type of traumatic brain injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and activation of trauma team. Results: Our analysis encompassed 2733 patients. Among these, patients in the unclear consciousness group (GCS ≤ 8) who underwent C-spine immobilization exhibited a higher mortality rate than those without immobilization. However, there was no statistically significant difference in mortality among patients with alert consciousness (GCS > 8). Multivariable logistic regression analysis revealed that advanced age (age ≥ 65), unclear consciousness (GCS ≤ 8), major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and the use of neck collars for immobilization (adjusted OR: 1.850, 95% CI: 1.240-2.760, p = 0.003) were significantly associated with an increased risk of mortality. Subgroup analysis indicated that C-spine immobilization was significantly linked to an elevated risk of mortality in older adults (age ≥ 65), patients with unclear consciousness (GCS ≤ 8), those with major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and individuals in shock (shock index > 1). Conclusions: While our findings do not advocate for the complete abandonment of neck collars in all suspected head and neck injury patients, our study suggests that prehospital cervical and spinal immobilization should be applied more selectively in certain head and neck injury populations. This approach is particularly relevant for older individuals (age ≥ 65), those with unclear consciousness (GCS ≤ 8), individuals experiencing major traumatic injuries (ISS ≥ 16 or RTS ≤ 7), and patients in a state of shock (shock index ≥ 1). Our study employs a retrospective cohort design, which may introduce selection bias. Therefore, in the future, there is a need for confirmation of our results through a two-arm randomized controlled trial (RCT) arises, as this design is considered ideal for addressing this issue.

Age, ASA-status, and Changes in NSQIP Comorbidity Indices Reporting in Facial Fracture Repair

OBJECTIVE

To evaluate the impact of age and the American Society of Anesthesiologists (ASA) classification on post operative outcomes as well as the changes in the National Surgical Quality Improvement Program (NSQIP) database reporting of comorbidity index variables in patients with facial fractures.

METHODS

The NSQIP database was queried for facial fracture repair CPT codes between 2012 and 2019 and for modified Frailty Index (mFI) and modified Charlson Comorbidity Index (mCCI) variables between years 2006 and 2018. The predominant question analyzed two preoperative risk factors: patient and ASA classification. Chi-square analysis, Kruskal-Wallis, Mann-Whitney, Spearman correlation, and multivariable logistic regression were used to evaluate age and ASA classification with wound dehiscence, superficial surgical site infection (SSSI), deep wound infection (DWI), readmission status, and return to the OR. The reporting of indices variables was evaluated with descriptive statistics.

CONCLUSION

In this large database with univariate analysis, patients with a higher ASA classification and older patients experience significantly increased risks of readmission, return to the OR, and longer hospital stays. On multivariate analyses, ASA classes II, III, and IV are independently associated with increased risk of readmission and return to the OR, while controlling for patient age. The reporting of all mFI and mCCI variables were consistent from 2006 to 2010, but after 2011, there has been inconsistent or absent reporting of variables, therefore, conclusions on the impact of comorbidities on facial fracture repair are unreliable.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2572-2577, 2023.

Traumatic hemorrhage of the thyroid as a work-related injury: a case report and review of the literature

Traumatic hemorrhage of the thyroid gland resulting from blunt injury to the neck is a very rare event. Particular neck positions can expose the thyroid to trauma, especially in motor vehicle collisions, falls, direct blows, or sport activities. Preexisting conditions such as goiters, adenomas, and cysts can increase the risk of bleeding, reducing the force required to rupture the gland and make the thyroid more prone to injury. The authors report the case of a 53-year-old man who was involved in a fire while working on maintenance of a liquid petroleum gas (LPG)-powered car. He subsequently presented to the emergency department with painful swelling of his right anterior neck with a palpable mass. CT scan showed a right thyroid hemorrhagic cyst. The worker reported that he had jumped into the car trunk to extinguish the fire and covered the gas tank nozzle with his own body to prevent dispersal of the accelerant. In this case, the medico-legal evaluation was useful to delineate between natural and traumatic causes of the injury. Medico-legal assessment is key in understanding the dynamics involved in work-related events to identify any legal responsibilities of the worker or the employer.

Upper cervical spine fracture patterns and blunt cerebrovascular injuries

PURPOSE

To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI).

METHODS

Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI.

RESULTS

Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01).

CONCLUSION

C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.

Risk Factors of Work-Related Head and Neck Injuries: A National Survey

Background

Occupational accidents made injuries in different parts of the body; two important parts of them are head and neck. We aimed to identify the risk factors of work-related head and neck injuries with using of a nationwide occupational accident data.

Methods

This analytical cross-sectional study was conducted on the nationwide data that was gathered in 2013-2018. The target population was industrialized and non-industrialized adults, aged 18 yr or older. Dependent variable was the head and neck injuries. The independent variables were included, age, sex, education level, work experience, job, shift work, injury cause, referred center, season, accident day, accident time, and action after accident. Univariate logistic regression analyses and subsequently, a multivariate logistic regression model was used for analysis.

Results

Out of the 17066 injured workers, 4072 (23.86%) subjects had head and neck injuries. The results of multivariate logistic regressions model showed, age ranges 30-39 (OR = 1.218; 95% CI: 1.036,1.433; P= 0.017), 40-49 (OR = 1.313; 95% CI: 1.044,1.652; P= 0.020), and >= 60 (OR=1.620; 95%CI: 1.028,2.553; P=0.038) and having male sex (OR = 1.657; 95% CI: 1.075,2.555; P= 0.022) were final work-related risk factors of head and neck injuries in Iran. Also winter season (OR = 1.212; 95% CI: 1.00,1.469; P= 0.050) could increase the head and neck injuries odds.

Conclusion

Older workers in Iran are more vulnerable against the occupational head and neck injuries. Moreover, having male sex was other risk factor of the head and neck injuries.

Patterns of Head and Neck Injuries in Urban India: A Multicenter Study

Objective

The pattern of head and neck injuries has been well studied in high-income countries, but the data are limited in low- and middle-income countries, which are disproportionately affected by trauma. We examined a prospective multicenter database to describe patterns and outcomes of head and neck injuries in urban India.

Study Design

Retrospective review of trauma registry.

Setting

Four tertiary public hospitals in Mumbai, Delhi, Kolkata.

Methods

We identified patients with isolated head and neck injuries using International Classification of Diseases, 10th Revision (ICD-10) codes and excluded those with traumatic brain and/or ophthalmic injuries and injuries in other body regions.

Results

Our cohort included 171 patients. Most were males (80.7%) and adults aged 18 to 55 years (60.2%). Falls (36.8%) and road traffic accidents (36.3%) were the 2 predominant mechanisms of injury. Overall, 35.7% required intensive care unit (ICU) admission, and 11.7% died. More than 20% of patients were diagnosed with “unspecified injury of neck.” Those with the diagnosis had a higher ICU admission rate (51.4% vs 31.3%, P = .025) and mortality rate (27.0% vs 7.5%, P = .001) than those without the diagnosis.

Conclusion

Isolated head and neck injuries are not highly prevalent among Indian trauma patients admitted to urban tertiary hospitals but are associated with high mortality. Over a fifth of patients were diagnosed with “unspecified injury of neck,” which is associated with more severe clinical outcomes. Exactly what this diagnosis entails and encompasses remains unclear.

Disrupting mechanotransduction decreases fibrosis and contracture in split-thickness skin grafting

Burns and other traumatic injuries represent a substantial biomedical burden. The current standard of care for deep injuries is autologous split-thickness skin grafting (STSG), which frequently results in contractures, abnormal pigmentation, and loss of biomechanical function. Currently, there are no effective therapies that can prevent fibrosis and contracture after STSG. Here, we have developed a clinically relevant porcine model of STSG and comprehensively characterized porcine cell populations involved in healing with single-cell resolution. We identified an up-regulation of proinflammatory and mechanotransduction signaling pathways in standard STSGs. Blocking mechanotransduction with a small-molecule focal adhesion kinase (FAK) inhibitor promoted healing, reduced contracture, mitigated scar formation, restored collagen architecture, and ultimately improved graft biomechanical properties. Acute mechanotransduction blockade up-regulated myeloid CXCL10-mediated anti-inflammation with decreased CXCL14-mediated myeloid and fibroblast recruitment. At later time points, mechanical signaling shifted fibroblasts toward profibrotic differentiation fates, and disruption of mechanotransduction modulated mesenchymal fibroblast differentiation states to block those responses, instead driving fibroblasts toward proregenerative, adipogenic states similar to unwounded skin. We then confirmed these two diverging fibroblast transcriptional trajectories in human skin, human scar, and a three-dimensional organotypic model of human skin. Together, pharmacological blockade of mechanotransduction markedly improved large animal healing after STSG by promoting both early, anti-inflammatory and late, regenerative transcriptional programs, resulting in healed tissue similar to unwounded skin. FAK inhibition could therefore supplement the current standard of care for traumatic and burn injuries.

The Osteosynthesis of the Mandibular Head, Does the Way the Screws Are Positioned Matter?

Currently, an increasing number of medical centers are treating mandibular head fractures surgically. Dedicated screws for compression osteosynthesis have been developed. However, due to the very limited size of the fractured bones and the considerable technical difficulties accompanying the execution of the fixation, there is little room for correction of the positioning and reinsertion of the screws. Therefore, knowing the optimal position of the fixation material is crucial for therapeutic success. The aim of this study is the evaluation of fixation screw position on the mandibular ramus height obtained in the treatment of the condylar head fracture. A total of 57 patients were included in this study. The loss of mandibular ramus height on computed tomography twelve months after mandibular head osteosynthesis was evaluated in relation to the initial distance of the screws from the fracture line, the angle of insertion of the screw into the bone, and the size of the protrusion to the inner side of the condyle. The relationship of the proximity of the screw to the fracture line, angulation, and the size of the protrusion with the loss of ramus height was confirmed. Conclusions: the optimal location for the superior screw is approx. 4 mm below the fracture line (with any angulation), inferior screw is approx. 8 mm (with any angulation), and anterior screw position is approx. 4-5 mm distant from fracture line with the best angulation of 130 degrees to the lateral mandible ramus surface in the coronal plane.

Clinical, Radiologic, and Endolaryngeal Findings in Laryngeal Fractures: A 15-Year Case Series

Objective

Laryngeal fractures are rare injuries; recent data describing these injuries and associated examination findings are limited. This study aims to describe injury etiology and outcomes associated with laryngeal fractures.

Study Design

Retrospective case series.

Setting

Academic tertiary center.

Methods

Patients with laryngeal fractures from 2005 to 2020 were identified in a retrospective chart review. Patient demographics, injury mechanisms, management, and voice outcomes were examined. Fracture type, radiologic, and endolaryngeal examination findings were analyzed for associations between fracture etiology and examination characteristics.

Results

Laryngeal fractures most commonly occurred at the thyroid cartilage. Fractures were most commonly due to sport-related injuries. Mechanism of injury was not associated with specific radiologic or endolaryngeal findings. Mechanism of injury was additionally not significantly associated with the need for intubation, surgical intervention, or tracheotomy. Fracture location was significantly associated with intubation requirement (P = .015), with 40% of patients with concomitant thyroid and cricoid fractures requiring intubation. Mechanism of injury significantly correlated with dysphonia at follow-up (P = .033). Mechanism of injury, fracture location, and surgical management were not associated with increased vocal fold injury or dysphonia.

Conclusion

There are no significant correlations between injury mechanism and fracture location, characteristics, radiologic findings, or endolaryngeal findings. These features emphasize the importance of a thorough and comprehensive laryngeal examination.

Delphi Method Consensus on Priority Global Otolaryngology-Head and Neck Surgery Conditions and Procedures

OBJECTIVE

The objective of this study was to develop an international expert consensus on priority otolaryngology-head and neck surgery conditions and procedures globally for which national health systems should be capable of caring.

STUDY DESIGN

The Delphi method was employed via a multiround online survey administered to attending otolaryngologists in an international research collaborative of >180 otolaryngologists in >40 countries.

SETTING

International online survey.

METHODS

In round 1, participants listed the top 15 otolaryngologic conditions and top 15 otolaryngology procedures for their World Bank regions. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as 50% of the round 2 Likert responses being ranked as "important" or "very important." Descriptive statistics were calculated for each round.

RESULTS

The survey was distributed to 53 experts globally, with a response rate of 38% (n = 20). Fifty percent (n = 10) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. Ten consensus surgical procedures and 10 consensus conditions were identified.

CONCLUSION

This study identified a list of priority otolaryngology-head and neck surgery conditions and surgical procedures for which all national health systems around the world should be capable of managing. Acute and infectious conditions with preventative and emergent procedures were highlighted. These findings can direct future research and guide international collaborations.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis

ABSTRACT

It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x[Combining Tilde] = 2330.6 PMP), 28,004 surgeons (x[Combining Tilde] = 83.5 PMP), and 746 training positions (x[Combining Tilde] = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P < 0.01), surgeon (70.8 versus 98.8, P < 0.01), training positions (0 versus 3.4, P < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density (P < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP (P < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Disrupting biological sensors of force promotes tissue regeneration in large organisms

Tissue repair and healing remain among the most complicated processes that occur during postnatal life. Humans and other large organisms heal by forming fibrotic scar tissue with diminished function, while smaller organisms respond with scarless tissue regeneration and functional restoration. Well-established scaling principles reveal that organism size exponentially correlates with peak tissue forces during movement, and evolutionary responses have compensated by strengthening organ-level mechanical properties. How these adaptations may affect tissue injury has not been previously examined in large animals and humans. Here, we show that blocking mechanotransduction signaling through the focal adhesion kinase pathway in large animals significantly accelerates wound healing and enhances regeneration of skin with secondary structures such as hair follicles. In human cells, we demonstrate that mechanical forces shift fibroblasts toward pro-fibrotic phenotypes driven by ERK-YAP activation, leading to myofibroblast differentiation and excessive collagen production. Disruption of mechanical signaling specifically abrogates these responses and instead promotes regenerative fibroblast clusters characterized by AKT-EGR1.

Humans and other large mammals heal wounds by forming fibrotic scar tissue with diminished function. Here, the authors show that disrupting mechanotransduction through the focal adhesion kinase pathway in large animals accelerates healing, prevents fibrosis, and enhances skin regeneration.

The need for craniofacial trauma and oncologic reconstruction in global surgery

The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.

Geriatric clinical screening tool for cervical spine injury after ground-level falls

BACKGROUND

A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI.

METHODS

The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set.

RESULTS

Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%).

CONCLUSION

Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.

Management of Nasal Trauma

Facial trauma can have long-lasting physical and mental consequences. Trauma to the nose is commonly seen in the emergency department. Nasal lacerations account for 7% of all facial lacerations. Thorough examination and documentation including photographs is important for documentation and creating a reconstruction plan. Underlying damage to cartilage or bone must be reconstructed initially or in a delayed fashion to recreate the pretrauma anatomy and function. There are several options for soft tissue nasal reconstruction, including local flaps, skin grafts, pedicle flaps, and free flaps. At present there is no standard of care for postoperative facial trauma wound care.

[Suicidal neck injury without vital organ damage]

We report a suicidal neck injury without vital organ damage. Trauma was made by scissors for suicidal purposes. Upon admission, the patient underwent X-ray examination in 2 planes, gastroscopy, bronchoscopy, Doppler ultrasound of the neck vessels. Extraction of scissors and wound drainage were carried out under endotracheal anesthesia. Postoperative period was uneventful.

Trends in opioid prescription for craniomaxillofacial trauma in the United States: An 11-year retrospective study of emergency room and office visits

BACKGROUND

Facial trauma is associated with significant long-term morbidity and pain. These patients are routinely prescribed opioid medication and are at risk for opioid dependence. Rates and trends in opioid prescription in the ambulatory setting for management of craniofacial trauma are unknown.

METHODS

The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data were analyzed from 2006 to 2016. Using International Classification of Diseases codes, 7,997,454 visits for craniomaxillofacial trauma were identified. Trends in opioid and nonopioid prescriptions were studied, with variables of interest including demographics, geographic region, expected source of payment, and injury location.

RESULTS

Over the study period, trends in both opioid and nonopioid prescriptions remained stable, with about 13.4% of all visits receiving opioid prescriptions. Patients aged 18 to 44 (P < .001) and lower face trauma (P = .047) were associated with increased rates, while Medicare and charity payers (P < .001) were associated with lower rates of opioid prescriptions. There was no significant difference in prescription rates across geographical regions, by ethnicity, or sex.

CONCLUSION

Opioid medication forms the cornerstone for ambulatory management of craniofacial trauma. Despite increased awareness and emphasis on multimodal pain management, opioid prescription trends have remained relatively stable over time.

Head and Neck Injuries Associated With Cell Phone Use

Importance

As cell phones gain more influence in daily life, they also become potentially more hazardous. Injuries resulting from cell phone use have long been reported largely in the context of driving-related incidents, but other mechanisms of injury have been underreported.

Objective

To assess the incidence, types, and mechanisms of head and neck injuries associated with cell phone use.

Design, Setting, and Participants

Retrospective cross-sectional study using data from a national database of individuals with head and neck injuries related to cell phone use who presented to emergency departments in the United States between January 1998 and December 2017.

Main Outcomes and Measures

Incidence, types, and mechanisms of injury related to cell phone use in the US population.

Results

A reported total of 2501 patients (1129 [55.0%] female, 795 [38.8%] white, and 772 [37.6%] aged 13-29 years) presented with injuries of the head and neck related to cell phone use; the estimated weighted national total was 76 043 patients (42 846 females [56.3%], 34 894 [45.9%] white, and 29 956 [39.4%] aged 13-29 years). The most commonly reported subsites of injuries in the head and neck region included the head (33.1% of estimated total); face, including eyelid, eye area, and nose (32.7%); and neck (12.5%). The most common injury diagnoses included laceration (26.3% of estimated total), contusion/abrasion (24.5%), and internal organ injury (18.4%). Age group distributions showed that most injuries associated with cell phone user distraction occurred among individuals aged 13 to 29 years (60.3%; Cramer V = 0.29). In addition, those younger than 13 years were significantly more likely to sustain direct mechanical injury from a cell phone (82.1%) than to have a cell phone use-associated injury (17.9%) (Cramer V = 0.305), whereas a cell phone use-associated injury was more likely than a direct mechanical injury to occur among those aged 50 to 64 years (68.2% vs 31.8%; Cramer V = 0.11) and those older than 65 years (90.3% vs 9.7%; Cramer V = 0.29).

Conclusions and Relevance

Cell phone-related injuries to the head and neck have increased steeply over the recent 20-year period, with many cases resulting from distraction. Although the disposition of most cases is simple, some injuries bear a risk of long-term complications. Many of these injuries occurred among those aged 13 to 29 years and were associated with common activities, such as texting while walking. These findings suggest a need for patient education about injury prevention and the dangers of activity while using these devices.

Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study

OBJECTIVES/HYPOTHESIS

Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes.

STUDY DESIGN

Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database.

METHODS

Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level.

RESULTS

In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]).

CONCLUSIONS

Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1109-E1116, 2021.

Current and Emerging Topical Scar Mitigation Therapies for Craniofacial Burn Wound Healing

Burn injury in the craniofacial region causes significant health and psychosocial consequences and presents unique reconstructive challenges. Healing of severely burned skin and underlying soft tissue is a dynamic process involving many pathophysiological factors, often leading to devastating outcomes such as the formation of hypertrophic scars and debilitating contractures. There are limited treatment options currently used for post-burn scar mitigation but recent advances in our knowledge of the cellular and molecular wound and scar pathophysiology have allowed for development of new treatment concepts. Clinical effectiveness of these experimental therapies is currently being evaluated. In this review, we discuss current topical therapies for craniofacial burn injuries and emerging new therapeutic concepts that are highly translational.

Head and neck injury in major trauma in Ireland: a multicentre retrospective analysis of patterns and surgical workload

PURPOSE

Head and neck injuries are common in major trauma patients, but the prevalence is poorly documented in the literature. This study aims to investigate this further, particularly in the context of increasing development of Irish and European trauma systems.

AIMS

To determine the prevalence of, and patterns behind head and neck injury in major trauma in an Irish population.

MATERIALS AND METHODS

The Trauma Audit Research Network database was analysed for major trauma patients (injury severity score > 15) with head and neck injuries admitted to any of the 26 participating hospitals in the Republic of Ireland between 2014 and 2017. The data was studied for patterns in the epidemiology of injuries and outcomes.

RESULTS

A total of 5364 patients were identified. Males were affected more than females (M:F 2.1:1). The most common mechanism of injury was falls. There were 1272 counts of soft tissue injury, and 5814 counts of bony injury recorded within the cohort. Twenty-six percent of patients underwent some form of surgical procedure. Median length of hospital stay was 8 days, and the 30-day survival rate was 90%.

CONCLUSIONS

A substantial number of Irish major trauma patients of all ages and genders sustain some form of head and neck injury. It produces significant injury and surgical workload involving input from multiple disciplines.

Facial fractures: classification and highlights for a useful report

In patients with facial trauma, multidetector computed tomography is the first-choice imaging test because it can detect and characterize even small fractures and their associated complications quickly and accurately. It has helped clinical management and surgical planning, so radiologists must communicate their findings to surgeons effectively. In Le Fort fractures, there is a breach between the pterygoid plates and the posterior maxilla. These fractures are classified in three basic patterns that can be combined and associated with various complications. Conceptualized when low-speed trauma was predominant, the Le Fort classification system has become less relevant giving more importance on maxillary occlusion-bearing segments. The classification of naso-orbito-ethmoid depends on the extent of injury to the attachment of the medial canthal tendon, with possible complications like nasofrontal duct disruption. Displaced fractures of the zygomaticomaxillary complex often widen the angle of the lateral orbital wall, resulting in increased orbital volume and sometimes in enophthalmos. Severe comminution or angulation can lead to wide surgical exposure. In orbital fractures, entrapment of the inferior rectus muscles can lead to diplopia, so it is important to assess its positioning and morphology. Orbital fractures can also result in injuries to the globe or infraorbital nerve. Frontal sinus fractures that extend through the posterior sinus wall can create a communication with the anterior cranial fossa resulting in leakage of cerebrospinal fluid, intracranial bleeding. It is essential to categorize fracture patterns and highlight features that may affect fracture management in radiology reports of facial trauma.

Head and Neck Trauma in a Rapidly Growing African Metropolis: A Two-Year Audit of Hospital Admissions

Understanding injury-related burdens is an essential part of trauma quality improvement programs aimed at decreasing morbidity and mortality. This is especially the case in low and middle-income country settings where data on injuries remains limited. The aim of this study was to audit the types of head and neck injuries, which have been diagnosed among patients admitted to a major national hospital in the context of a rapidly growing sub Saharan city. Data were collected retrospectively for head and neck trauma from the Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania from the years 2016 and 2017. Distribution of ICD-10 codes by age and sex for the five most common diagnoses were determined using frequencies and percentages. The most common diagnosis was ICD-10-S02 (fracture of skull and facial bones) with 277 cases (44.1%), which was followed by S05 (injury of the eye and orbit), 114 cases (18.2%), and S09 (other and unspecified injuries of head) 77 cases (12.3%). The mean ages of admission for these three diagnoses were 28.1 (SD: 11.6), 23.8 (SD: 18.9), and 30.8 (SD: 18.0) years, respectively. This study provides information on the overall burden of head and neck trauma at a major regional tertiary care facility. It provides an initial understanding of the burden of head and neck trauma and suggests follow-up in the form of clarification of injury mechanisms and contextual factors for future work.

No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis

Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

To stitch or not to stitch: A case review: Auricular lacerations involving cartilage management in the emergency department

Patients with Parkinsonism are at risk of frequent falls by virtue of their unstable gait. Auricular lacerations involving the cartilage are usually managed by Plastics Surgeons. Patient Mr Jones (an alias for this case review) had sustained a significant full thickness auricular laceration that was complicated by a past medical history with Parkinson's disease. This case review summarises a nurse practitioner's (NP) clinical decision-making processes and the experience in the management and treatment of auricular cartilage lacerations in the emergency department.

Laryngeal fracture presentation and management in United States emergency rooms

OBJECTIVES/HYPOTHESIS

There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.

STUDY DESIGN

Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

METHODS

The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.

RESULTS

There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.

CONCLUSIONS

Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2341-2346, 2019.

[The wounds of the neck]

The author presents his personal observation of a complex wound on the neck treated with a favourable outcome. Prior to the surgical intervention, the efficient intubation was performed by an anesthesiologist through the wound at the frontal surface of the neck which communicated with the cavity of the oropharynx. The revision showed the injury to the superior thyroid artery branching off from the external carotid artery. Ligation of the vessel did not cause the deterioration of cervical circulation. The long-term hemostasis was achieved, Thereafter, the mid-tracheostomy was performed and the nasogastric tube installed. The wound was copiously washed with an antiseptic solution. The layer by layer suturing of the mucous membrane of the oropharynx was carried out. The hyoid bone was sutured to the soft tissues of the floor of the mouth, and the oropharynx was reconstructed. The soft tissues were juxtaposed and sutured. The rubber graduates were removed on day 3 after the termination of the surgical intervention. The tracheostomy tube and nasogastric tube were removed on the 7^th day and the 10^th day after surgery respectively. The wound healed by primary intention. The patient was discharged from the hospital in the satisfactory condition on the 14^th postoperative day.

Historical Case of Cervical Penetrating Wound: From First Aid to Surgical Intervention

Objective

We report a case of cervical penetrating wound by posing the problem of its support and by analyzing the chain of survival of a patient to human sacrifice.

Case Report

It was an 11-year-old boy admitted to the hosting service of cervical penetrating wound emergency occurring in a context of human sacrifice by weapon (knife). On admission, the conscious patient had a left cervical hematoma at the level of the cervical zone II and severe signs of acute anemia. The exploratory cervicotomy, carried out 12 hours after the trauma under transfusion, allowed us to highlight a section of the front edge of the sternocleidomastoid and previous jugular muscles under hyoid. We noted the presence of a linear wound of 1 cm at the level of the left internal jugular vein. The wound of the internal jugular vein has been repaired with the Prolene 4.O. The outcome was good, allowing the exit 10 days after cervicotomy.

Conclusion

The causal circumstances of cervical penetrating wounds are diverse. Their importance or their severity depends on the causative circumstances dominated by aggression and attempts to autolysis. Human sacrifice, with use of the weapon, is an exceptional circumstance.

Stem cell therapy for reconstruction of alveolar cleft and trauma defects in adults: A randomized controlled, clinical trial

BACKGROUND

Stem cell therapy with bone marrow-derived mesenchymal stem cells is a promising tissue engineering strategy to promote regeneration of craniofacial bone.

PURPOSE

To determine whether cell therapy with ex vivo expanded stem cell populations would be safe and efficacious in the regeneration of large alveolar defects in patients with a history of cleft palate or craniofacial trauma.

MATERIALS AND METHODS

Eighteen patients (10 patients with traumatic injury and 8 patients with cleft palate) presenting with missing teeth associated with horizontal alveolar bone deficiencies were included in this randomized controlled clinical trial. Patients were randomized to receive either conventional autogenous block grafts or stem cell therapy. After a healing period of 4 months the treated sites were re-entered and the bone width re-assessed prior to implant placement. Implant stability was evaluated through torque testing of the implant upon insertion and at 6 months postloading.

RESULTS

The mean gain in bone width was 1.5 ± 1.5 mm in the stem cell therapy group and 3.3 ± 1.4 mm in the control group. Overall, bone gain was higher in trauma patients as compared to patients with cleft palate, for both the control and the stem cell therapy groups. Most postoperative complications were wound dehiscences and incision line openings. Implants were placed successfully in 5 out of 10 patients in the stem cell therapy group and in all 8 patients in the control group. One implant from the control/cleft palate group failed before loading, while the rest of the implants were loaded successfully and remained stable at 6 months. The patients who did not receive implants were re-treated with autogenous block bone graft.

CONCLUSION

The ability of stem cells to treat large alveolar defects is safe, yet, their ability to completely reconstitute large alveolar defects is limited. This approach requires further optimization to meet the outcomes seen using current methods to treat large defects, particularly those resultant of cleft palate.

Mandibular Degloving: A Case Report and Literature Review

BACKGROUND

Degloving injuries of the extremities are well documented; however, there are few reports of degloving injuries to the mandible. A literature review demonstrates several cases of mandibular degloving in pediatric patients. However, no isolated mandibular degloving injuries have been reported in adults.

CASE REPORT

We report a case of a 21-year-old male who presented to the emergency department with facial trauma after a motorcycle accident. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. Following completion of maxillofacial computed tomography after primary and secondary survey, the intraoral lesion was found to be a degloving injury of the mandible. This injury was irrigated with bacitracin and betadine before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Facial trauma is a common presentation in the emergency department. It is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. Without a high level of suspicion, such lesions may be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity.