Clinical-embryological and radiological correlations of oculo-auriculo-vertebral spectrum using 3D-CT

Three-dimensional imaging of soft and hard facial tissues in patients with craniofacial syndromes: a systematic review of methodological quality

OBJECTIVES

To systematically review the methodological quality of three-dimensional imaging studies of patients with craniofacial syndromes and to propose recommendations for future research.

METHODS

PubMed, Embase and Cochrane databases as well as Grey literature were electronically searched. Inclusion criteria were patients with genetic syndromes with craniofacial manifestations and three-dimensional imaging of facial soft and/or hard tissues. Exclusion criteria consisted of non-syndromic conditions or conditions owing to environmental causes, injury or trauma, facial soft and hard tissues not included in the image analysis, case reports, reviews, opinion articles. No restrictions were made for patients' ethnicity nor age, publication language or publication date. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

The search yielded 2228 citations of which 116 were assessed in detail and 60 were eventually included in this review. Studies showed a large heterogeneity in study design, sample size and patient age. An increase was observed in the amount of studies with time, and the imaging method most often used was CT. The most studied craniofacial syndromes were Treacher Collins, Crouzon and Apert syndrome. The articles could be divided into three main groups: diagnostic studies (34/60, 57%), evaluation of surgical outcomes (21/60, 35%) and evaluation of imaging techniques (5/60, 8%). For comparative studies, the median MINORS score was 13 (12-15, 25-75th percentile), and for non-comparative studies, the median MINORS score was 8 (7-9, 25-75th percentile).

CONCLUSIONS

The median MINORS scores were only 50 and 54% of the maximum scores and there was a lack of prospective, controlled trials with sufficiently large study groups. To improve the quality of future studies in this domain and given the low incidence of craniofacial syndromes, more prospective multicentre controlled trials should be set up.

Relationship between Mandibular Ramus Height and Masticatory Muscle Function in Patients with Unilateral Hemifacial Microsomia

Objective

To clarify the relationship between mandibular ramus height and function of masticatory muscles in patients with hemifacial microsomia.

Design

Retrospective study of imaging and physiological data.

Setting

Images and physiological data were obtained from the records of Sapporo Medical University Hospital.

Patients

A total of 29 patients with hemifacial microsomia who showed Pruzansky grades I, II deformity.

Main Outcome Measures

Mandibular ramus height and masticatory muscle volume were evaluated with multi-detector row computed tomography. The electromyographic value was measured by the K7 Evaluation System. The hemifacial microsomia patients were classified into three groups based on the mandibular ramus height ratio of the affected and unaffected sides: group 0, > 1.00; group 1, 1.00 to 0.85; group 2, < 0.85. The Tukey-Kramer method and Games-Howell method were used to determine correlations between parameters.

Results

Decreased mandibular ramus height was significantly correlated with both reduced electromyographic values of the masseter muscle (P < .05) and the amount of mandibular lateral deviation at the time of maximum opening (P < .05) on the affected side. These differences were prominent in unilateral hemifacial microsomia patients classified as group 2.

Conclusions

Decreased mandibular ramus height may cause dysfunction of the masseter muscles but not the temporal muscle on the affected side in patients with hemifacial microsomia.

Goldenhar Syndrome: A rare case report

Goldenhar Syndrome or oculoauriculovertebral spectrum is a complex syndrome characterized by an association of maxillomandibular hypoplasia, deformity of the ear, ocular dermoid and vertebral anomalies and the most severe form of hemifacial microsomia. Here, we describe a 26-year-old male patient with unilateral hemifacial microsomia, preauricular ear tags, macrosomia on the right side of the face.

Surgical Classification of the Mandibular Deformity in Craniofacial Microsomia Using 3-Dimensional Computed Tomography

Background:

Grading systems of the mandibular deformity in craniofacial microsomia (CFM) based on conventional radiographs have shown low interrater reproducibility among craniofacial surgeons. We sought to design and validate a classification based on 3-dimensional CT (3dCT) that correlates features of the deformity with surgical treatment.

Methods:

CFM mandibular deformities were classified as normal (T0), mild (hypoplastic, likely treated with orthodontics or orthognathic surgery; T1), moderate (vertically deficient ramus, likely treated with distraction osteogenesis; T2), or severe (ramus rudimentary or absent, with either adequate or inadequate mandibular body bone stock; T3 and T4, likely treated with costochondral graft or free fibular flap, respectively). The 3dCT face scans of CFM patients were randomized and then classified by craniofacial surgeons. Pairwise agreement and Fleiss' κ were used to assess interrater reliability.

Results:

The 3dCT images of 43 patients with CFM (aged 0.1–15.8 years) were reviewed by 15 craniofacial surgeons, representing an average 15.2 years of experience. Reviewers demonstrated fair interrater reliability with average pairwise agreement of 50.4 ± 9.9% (Fleiss' κ = 0.34). This represents significant improvement over the Pruzansky–Kaban classification (pairwise agreement, 39.2%; P = 0.0033.) Reviewers demonstrated substantial interrater reliability with average pairwise agreement of 83.0 ± 7.6% (κ = 0.64) distinguishing deformities requiring graft or flap reconstruction (T3 and T4) from others.

Conclusion:

The proposed classification, designed for the era of 3dCT, shows improved consensus with respect to stratifying the severity of mandibular deformity and type of operative management.

Developmental maxillofacial anomalies

There is a wide variety of developmental maxillofacial anomalies secondary to defective transformation of the first pair of pharyngeal arches into adult structures. Computed tomography and magnetic resonance imaging are essential to precisely define aberrant maxillofacial anatomy and guide appropriate management. This review article provides an overview of maxillofacial embryogenesis, clinical symptoms, and characteristic imaging features of several anomalies, including choanal atresia, congenital nasal piriform aperture stenosis, dacryocystoceles, nasolacrimal duct stenosis, cleft lip and palate, micrognathia, and midline nasal masses. Finally the major features of common first pharyngeal arch syndromes are discussed.

Radiological evidence of Goldenhar syndrome in a paleopathological case from a South German ossuary

We investigated the skull of a juvenile living in Southern Germany between 1400 and 1800 A.D. A remarkable hemifacial microsomia led to further detailed computed tomographic examination especially of the petrous bone revealing a total bony atresia of the external auditory canal as well as distinct anomalies of the middle ear on the same side. The combination of these findings strongly suggests the diagnosis of Goldenhar syndrome. This very heterogeneous syndrome affects primarily aural, ocular, oral and mandibular development, whereby the constellation of anomalies indicate their origin at approximately 30-45 days of gestation, caused by genetic or intrauterine factors. Despite the lack of clinical information and the absence of soft tissue it was possible to perform a differential diagnosis in this palaeopathological case. Thereby, the use of modern modalities of image reconstructions in this computed tomographic clearly enhanced the supposed diagnosis.

Aplasia of the mandibular condyle

A rare case of aplasia of the mandibular condyle is presented along with the tomographic findings. A 31-year-old Caucasian woman presented with a main complaint of facial asymmetry. No family history or any trauma was found. A CT study was performed and the sagittal CT view demonstrated a complete absence of the left condyle. This case of unknown aetiology was thoroughly examined and, based on clinical findings, we suggest that it could be of developmental origin.

Clinical and imaging correlations of Treacher Collins syndrome: report of two cases

Mandibulofacial dysostosis (Treacher Collins Syndrome) is an autosomal dominant genetic disorder that probably derives from inhibition of the facial structures from the first and second branchial arches. The facial pattern of the syndrome is a convex facial profile with a prominent nose above a retruded chin. The eyes are deformed by antimongoloid slant of the palpebral fissures and facial bones are hypoplastic. The alterations are caused by mutation in gene 5q32-33.1, which encodes the nucleolar phosphoprotein treacle. Computed tomography images are able to demonstrate craniofacial bones, allowing the morphological analysis of these bones in individuals with complex deformities. The purpose of this paper is to present the results of a clinical and computed tomography investigation of two patients with Treacher Collins syndrome.

Chronic rhinosinusitis in congenital craniofacial malformations

OBJECTIVES

To review developmental abnormalities and iatrogenic alterations in sinus anatomy that may predispose patients with congenital craniofacial malformations to chronic rhinosinusitis.

STUDY DESIGN

Retrospective study.

METHODS

Seven patients with craniofacial malformations who were surgically treated by the senior author were included in the study. All were diagnosed with chronic rhinosinusitis refractory to medical management. Four patients had undergone previous corrective craniofacial surgery, and three of these patients developed iatrogenic sinus disease. Demographic data, diagnoses and anatomical abnormalities were included.

RESULTS

Abnormal sinus anatomy was present in all patients, most commonly skull base abnormalities and dehiscent lamina papyracea. All patients underwent successful endoscopic surgical management (n = 7) for their chronic rhinosinusitis. Two patients had adjuvant external procedures. There were no complications and no recurrences after a mean follow up time of 15 months.

CONCLUSIONS

Otolaryngologists should be aware of the possibility of chronic rhinosinusitis in patients with craniofacial malformations. Careful preoperative evaluation of radiographic studies should be performed as most of these patients will have abnormal sinus anatomy. In addition, patients who undergo surgery to correct their craniofacial malformations are susceptible to altered sinus anatomy that may predispose them to the development of iatrogenic chronic rhinosinusitis.

CT interpretation of craniofacial anomalies: a comparative analysis by undergraduate dental students

The aim of this study was to evaluate the accuracy and reproducibility of computed tomography (CT) image interpretation made in axial slices (2D-CT) and 3D reconstructed images (3D-CT) of patients with craniofacial anomalies. The analyses were made by undergraduate dental students, and compared with the diagnoses considered upon surgical intervention. Computed tomography of 43 patients were analyzed independently by three calibrated examiners (undergraduate students) with, respectively, one, two, and three semesters of experience in craniofacial CT training and interpretation. The analysis of 2D-CT and 3D-CT images were performed at distinct times using an independent workstation associated with a specific computer graphics software for volumetric images. The analysis of inter-examiner agreement and of the agreement between observers and the gold standard was performed using the Kappa test. The accuracy evaluation presented a progressively higher value for examiners with progressively broader experience in 2D-CT and 3D-CT image interpretation. 3D-CT analyses allowed a higher inter-examiner agreement (1 - 0.896) than 2D-CT analyses (1 - 0.614). 3D-CT was considered more precise and accurate than 2D-CT for all students' evaluations. The reproducibility and accuracy varied according to the experience in CT interpretation, and the most experienced student achieved results closer to the gold standard.