Horizontal eye position in thyroid eye disease: a retrospective comparison with normal individuals and changes after orbital decompression surgery

Objective

To compare horizontal eye positions between proptotic thyroid eye disease patients and normal individuals, and to examine positional changes after orbital decompression surgery in thyroid eye disease patients.

Methods

The present case-controlled and retrospective comparative study included 78 proptotic thyroid eye disease patients who underwent bilateral orbital decompression surgery [lateral orbital wall decompression (Group L), 47 patients; medial orbital wall decompression (Group M), 9 patients; and balanced orbital decompression (Group B), 22 patients] and 143 age-matched healthy volunteers as controls. The interpupillary distance was measured to determine horizontal eye positions before and 3 months after surgery in thyroid eye disease patients and was also examined in control eyes. Horizontal eye shifts were calculated by subtracting postoperative from preoperative interpupillary distances.

Results

Preoperative interpupillary distances in thyroid eye disease patients were significantly larger than in controls. The interpupillary distances were significantly decreased postoperatively in Groups M and B, but were significantly increased in Group L. The order of the magnitude of the horizontal shifts was Groups M>B>L.

Conclusions

Proptotic thyroid eye disease patients preoperatively showed laterally displaced eyes in comparison with controls. However, the eyes shifted medially after the medial orbital wall decompression and the balanced orbital decompression, although the former showed more shift. Medial orbital wall or balanced orbital decompression can be used to correct both lateral and anterior displacement of the eyes.

Atypical midline cleft with duplication of the metopic suture

INTRODUCTION

In contrast to the common clefts of the lip, alveolus and palate, the atypical clefts of the face may come in myriad patterns of clinical expression and are often not easy to define.

PURPOSE

In this report, a case of median craniofacial dysraphia is described.

PATIENT

At presentation, the 3-month-old male patient had a bilateral complete cleft of the lip, alveolus and palate. The nose was wide and a horn was present on the nasal dorsum. 3-D CT AND MRI REVEALED: Duplication of the metopic suture ending at the wide anterior fontanel; orbital hypertelorism; midline cranial cleft ending just superior to the nasal dorsum; frontoethmoidal encephalocoele and holoprosencephaly. The presence of two metopic sutures was confirmed during surgery.

CONCLUSION

The presented case carries the characteristics of the median cleft face syndrome. However, it differs from similar cases in two respects. First, the patient had two metopic sutures, one on either side of the cranial extension of the median cleft. Second, the patient had a bilateral cleft lip in contrast to the expected median cleft lip deformity.

Hypertelorism: the importance of three-dimensional imaging and trends in the surgical correction by facial bipartition

BACKGROUND

The technique of facial bipartition has been considered a great advance in achieving a more natural appearance in hypertelorism correction.

METHODS

Fourteen patients who had undergone hypertelorism correction by facial bipartition were retrospectively studied to analyze the role of three-dimensional computed tomographic reconstruction in the evaluation of the deformity and preoperative planning. The procedure and surgical details that can improve the outcome were described. A reproducible set of three-dimensional measurements that can help in preoperative patient evaluation was determined based on information obtained using the Analyze/AVW 3.1 system (Biomedical Imaging Resource, Mayo Foundation, Rochester, Minn.).

RESULTS

In this series, the most common diagnosis was frontonasal dysplasia (64.3 percent). Five patients had second-degree (35.7 percent) and nine had third-degree hypertelorism (64.3 percent). The three-dimensional scans were shown to be highly accurate in predicting the degree of deformity. There was a significant difference in the preoperative and postoperative interdacryon distance and midface height (p < 0.05) but not in the bitemporal distance (p = 0.08). The simulation correlated significantly with the postoperative result when interdacryon distance and midface height were analyzed (0.736 and 0.999).

CONCLUSIONS

Facial bipartition provided a three-dimensional correction of hypertelorism. Three-dimensional imaging can definitely be considered an extra tool for accurate surgical planning and helping the family understand the surgical procedure and the end result.

First-trimester three-dimensional ultrasonographic findings in a fetus with frontonasal malformation

A case of a frontonasal malformation observed during the first trimester with three-dimensional ultrasonography and fetoscopy is reported. Absence of the nasal bone and a poorly characterized nose were visualized at 11 5/7 weeks by two-dimensional ultrasonography. Rendered three-dimensional ultrasound images revealed absence of the nasal bridge, widely spaced frontal bones and hypertelorism. Fetoscopy, performed at 12 3/7 weeks, confirmed the hypertelorism and showed a broad translucent nose with a flat nasal bridge. The final diagnosis of frontonasal malformation was made at autopsy after pregnancy termination. A review of prenatally diagnosed cases as well as the various syndromes having frontonasal malformation as a common denominator is presented.

The role of integrated imaging techniques for prenatal prediction of phenotype in two cases of facial anomalies

OBJECTIVES

Fetal face malformations represent one of the most challenging prenatal diagnoses mainly because of the wide range of morphological features involved. We tested an approach based on a combination of conventional two-dimensional ultrasound with the more recent three-dimensional technique plus magnetic resonance imaging, in order to improve parents' understanding of fetal face anomalies, thereby facilitating parent counselling.

METHODS

Two cases of fetal facial anomaly were studied using these combined techniques; one had severe micrognathia and malformation of the ears with preauricular tags, while the other had bilateral dacryocystocele and severe hypertelorism.

RESULTS

The images generated by three-dimensional ultrasound enabled the parents to visualize their child immediately and helped them to adjust to the diagnosis of facial defects and its clinical consequences.

CONCLUSIONS

An approach based on combined use of different imaging techniques was found useful in both cases.

[Microphthalmos and hypertelorism as diagnostic index in ultrasound diagnosis of Fraser syndrome]

Fraser syndrome is a rare genetic syndrome with abnormalities of the head, lungs, kidneys, and limbs. A prenatal diagnosis of FS can be done in families with risk, using foetal ultrasonography. However, a wide qualitative and quantitative variability of possible abnormalities makes the diagnosis in utero notably questionable. We present the results of foetal ultrasonography in a tertigravida, had delivered two children with FS. Signs of foetal hypertelorism and microphthalmia, both traits typical for FS, were detected based on outer and inner orbital diameters and ocular diameters in 28 and 32 weeks of pregnancy. The clinical and pathological examinations after birth confirmed the diagnosis of FS. Our observation suggests that eye anomalies may prompt the diagnosis of FS even if characteristic lung and kidney abnormalities are absent. Therefore, we propose to regularly assess eye dimensions and distance, when performing any foetal ultrasonography in families with of FS.

Choanal atresia and rare craniofacial clefts: report of three cases with a review of the literature

OBJECTIVE

This retrospective study reports three cases associating choanal atresia (CA) and rare craniofacial clefts (RCFCs) described in Tessier's classification. Although still discussed, these two malformations could derive from the same embryopathogenic context, with an anomaly of migration of the neural crest cells as a common factor. In two of the three cases presented, the RCFC was diagnosed during the neonatal period, and the third case (case 3) was diagnosed at the age of 12 years. The knowledge of this malformative association must permit the diagnosis of CA as early as the neonatal period or through the thorough and directed examination of the children as part of the follow-up.

[X-ray manifestations of severe congenital deformities of the visceral cranium]

The paper discusses the most rational algorithm of an X-ray study and its results obtained while analyzing X-ray findings in 320 patients with severe congenital deformities of the visceral cranium. The malformations are shown to involve not only the visceral cranium, but also the cerebral cranium and its base and they can be rarely assigned to any of the known syndromes as they have frequently something in common. The most rational scheme of a X-ray study is presented.

Bony orbital distances among the Filipino population

Six hundred and seventy seven radiographs were selected from the logs of films taken in a major hospital in Metro Manila, Philippines over the course of the previous year. Two hundred and eighty-eight female and 389 male, healthy Filipinos between the ages of birth and twenty years were selected based on the availability of a modified Waters' projection and lateral skull film taken at the same time. Measurements for the lateral orbital wall were made at the site of the suture on the medial surface of the zygomatic bone. The medial orbital wall measurement was the distance between the dacrya using a correction factor formula of CF = D-d/D where D is the target film distance and d is the object film distance (1). The actual bony measurements were calculated. The data was gathered and plotted according to sex and in age in years. Graphs were generated using SAS over a graph software. Lines were smooth using cubic spline technique developed by Reinsch with the smoothest value of 75 (2). The mean plus two, four, and six standard deviations were included in each of the curves.

Ultrasound diagnosis of craniosynostosis

OBJECTIVE

To retrospectively study prenatal ultrasound images of patients with craniosynostosis to determine the extent to which prenatal diagnosis is possible.

METHOD

Prenatal ultrasound images of 19 patients with postnatally diagnosed metopic or coronal suture craniosynostosis were retrospectively reviewed. The 26 ultrasound examinations obtained were compared with normal images and tables of gestation.

RESULTS

It was not possible to diagnose craniosynostosis in the first trimester. In the second trimester, Kleeblattschädel was diagnosed at 20.5 weeks. A multilobular shape to the skull and diastasis of the frontotemporal suture was identified. In a second child with Kleeblattschädel, the cephalic index was above normal 86.4 (normal range 70 to 86), and the head circumference to abdominal circumference was increased. In the third trimester, the head shape deformation was more obvious. Brachycephaly diagnosis was made in the second trimester. In Crouzon syndrome the hypertelorism was identified at 19.9 weeks. Plagiocephaly was diagnosed at 21.4 weeks. In trigonocephaly the reduced cephalic index was noted at 18.8 weeks. In the third trimester, the deformity was diagnosed in all cases.

CONCLUSION

No diagnosis of craniosynostosis was made in the first trimester. In the second trimester, it was possible to diagnose Kleeblattschädel, trigonocephaly, brachycephaly (bilateral coronal suture craniosynostosis), and plagiocephaly (unilateral coronal suture craniosynostosis) in nine of the examinations. In the third trimester and at term, it was possible to diagnose previously listed conditions from six of the seven examinations obtained. Kleeblattschädel was suspected during original examination. A total of 15 examinations of 26 were correctly diagnosed during this investigation.

Public domain computer-aided surgery (CAS) in orthodontic and maxillofacial surgery

BACKGROUND

Computer-aided virtual three-dimensional (3D) surgical simulation assists the necessary visual understanding of complex pathological situations but has so far been dependent on expensive hardware and software.

METHOD

For the first time a non-commercial, user-orientated application for orthognathic and craniofacial surgical simulation has been introduced, based on freeware NIH Image 1.62 provided by the National Institute of Mental Health (NIMH). Use and limitations are demonstrated here by the example of hypertelorism surgery. The osteotomy lines and the amount of resection for outward positioning of the orbits were determined by the surgeon on a workstation using CT data. Possible movement patterns of the osteotomy fragments were rotations, sagittal and transversal movements or combinations of these. The program then allows the calculation of anatomical distances on the screen in a 1:1 relation. Normative values according to age and pathological anatomy determine the degree of displacement. The program calculates the new position of the osteotomy fragments and transfers the data of the segment movement to the original CT data.

RESULTS

3D visualization of bone and soft tissue contours have been produced with an acceptable quality on a workstation for the demonstration and visual understanding of the surgical plan. Evaluation of a postoperative CT showed that the amount of movement and size of bone resection in the simulation was slightly overestimated rather than underestimated. This was also dependent on the complexity of the pathological anatomy and on how experienced the surgeon was.

CONCLUSION

The use of 3D simulation programs allows a better understanding of the pathological anatomy in all dimensions, and in many cases enables limitations to be recognized in advance. The public domain program makes a major contribution to the quality of orthognathic and craniofacial surgical planning through cost-free usability, and supports continuous development and exchange of experience.

Brains and faces in holoprosencephaly: pre- and postnatal description of 30 cases

OBJECTIVE

To investigate the prenatal appearance of the holoprosencephaly spectrum.

METHODS

A database of 1750 fetuses with congenital anomalies identified by ultrasound was prospectively collected from 1987 to 2000. Among them, 30 cases (1.7%) with holoprosencephaly were prenatally identified and described.

RESULTS

The prevalence of holoprosencephaly in the Health Region of the National Center for Fetal Medicine in Norway was 1.26 : 10 000; the sex distribution (male : female) was 1.4 : 1. Holoprosencephaly was found in one dichorionic twin pregnancy and one pair of conjoined twins. Among the 30 cases of holoprosencephaly, 18 were alobar, five were semilobar, two were lobar, two were lobar variants, and three were anencephalic. The facial features varied considerably. Sixty-seven per cent (20/30) had associated structural anomalies that were not related to the cerebral and facial holoprosencephaly condition. Thirty-seven per cent (11/30) had detectable chromosome aberrations and 23% (7/30) had nonchromosomal syndromal origin. The size or shape of the head was abnormal in 83% (25/30) of holoprosencephaly cases.

CONCLUSION

This study indicates that holoprosencephaly represents a heterogeneous entity with different etiologies and clinical appearances. The fact that holoprosencephaly features are found associated with particular conditions such as fronto-nasal dysplasia (2/30; 6.7%), agnathia-otocephaly (3/30; 10%), and anencephaly (3/30; 10%), suggests that these may be underreported conditions in other large holoprosencephaly series.

An atypical case suggesting the possibility of overlap between Malpuech and Juberg-Hayward syndromes

Malpuech syndrome and Juberg-Hayward syndrome are considered to be distinct disorders of orofacial clefting. We present details of a patient whose clinical presentation closely resembles the profile of Malpuech syndrome, but whose radiological features are more in keeping with published observations in Juberg-Hayward patients.

A new technique for the repair and reconstruction of frontoethmoidal encephalomeningoceles by medial orbital composite-unit translocation

A frontoethmoidal encephalomeningocele is a herniation of brain and meninges through a congenital bone defect in the skull at the junction of the frontal and ethmoidal bones. Between 1992 and 1999, we treated 145 cases of frontoethmoidal encephalomeningocele. Before 1993, the operation was performed in two stages. An intracranial repair by neurosurgeons preceded the external extirpation of the mass. In 70 cases that were operated on after 1993, a one-stage closure of the skull defect with a medial orbital composite-unit translocation technique was used. The medial orbital rim on each side, with intact periosteum, medial canthal ligament and lacrimal apparatus, was translocated as a unit to the midline. The advantages of this technique are that it allows convenient access to resect the herniation mass and close the defect, it restores normal interorbital and intercanthal distances and it eliminates the need for a transnasal medial canthopexy. Augmentation rhinoplasty can be avoided in most cases by tilting the composite unit with its preserved blood supply.

Surgical risk factors in Larsen's syndrome

The authors report on a child with typical Larsen's syndrome with some rare findings such as mixed-type hearing loss and with some potentially fatal operative risks including laryngomalacia and cervical instability. A few deaths with Larsen's syndrome have been reported associated with various fatal risks such as spinal instability. Therefore, laryngomalacia and several other potentially fatal risks are presented in this report as awareness may prove essential to orthopedic surgeons.

Prenatal sonographic diagnosis of Aarskog syndrome

In 1970, Aarskog described a rare X-linked developmental disorder characterized by short stature in association with a variety of structural anomalies involving mainly the face, distal extremities, and external genitalia (faciodigitogenital syndrome). The major facial manifestations of this syndrome include hypertelorism, broad forehead, broad nasal bridge, short nose with anteverted nostrils, long philtrum, widow's peak hair anomaly, and ocular and ear anomalies. Limb abnormalities consist of short broad hands, brachydactyly, interdigital webbing, hypoplasia of the middle phalanges, proximal interphalangeal joint laxity with concomitant flexion and restriction of movement of distal interphalangeal joints, and flat broad feet with bulbous toes. Genital anomalies are characteristics and include shawl scrotum, cryptorchidism, and inguinal hernia. Most affected patients have normal intelligence, but some authors have noted mild neurodevelopmental delay in up to 30% of the cases. We describe a case of Aarskog syndrome diagnosed prenatally by sonography at 28 weeks' gestation in a high-risk pregnancy for this disorder.

Quantitative assessment of osseous, ocular, and periocular changes after hypertelorism surgery

The purpose of this study was to develop a methodology to quantify osseous, ocular, and periocular fat changes caused by correction of orbital hypertelorism to test the hypothesis that there is a quantitatively predictable relationship between the movement of the osseous orbit and that of the ocular globe. A retrospective review was performed of 10 patients who were status post unilateral or bilateral transcranial medial orbital translocation, for whom there were archival digital data for preoperative and postoperative (mean interval = 30 months) three-dimensional computed tomographic (CT) scans. In addition to standard demographic and surgical data, the clinical preoperative and postoperative interpupillary and intermedial canthal distances were recorded. By using a computer graphics workstation, the CT digital data were registered to four surgically unaltered anatomic fiducial points to allow longitudinal quantitative comparisons. The following three-dimensional measurements were made for each patient preoperatively and postoperatively: interdacryon and interocular centroid distances, and on a standard series of three horizontal and two vertical planes, the position of the medial and lateral orbital walls, and the thickness of the medial and lateral periorbital fat (20 orbits). CT digital distances were compared with similar clinical distances when possible. The age at operation ranged from 4.0 to 12.5 years (mean, 6.6 years). The reduction in interdacryon distance exceeded the reduction in intercentroid distance (mean interdacryon change = -5.3 mm versus mean intercentroid change = -2.7 mm). Although there was a strong correlation between the amount of reduction of the lateral orbital wall and intercentroid distances, there was only a moderate correlation between the reduction in the intercentroid distance and that of the medial orbital wall. Similarly, there was a moderate correlation between the decrease in thickness of the lateral periorbital fat and the reduction of intercentroid distance but not of the medial orbital fat. In conclusion, medial translocation of the orbit does not produce equivalent movement of the ocular globe; neither the intermedial canthal nor the interdacryon distance is a useful predictor of ocular centroid position; and if the goal of hypertelorism operation is reduction of interocular distance, then CT measurement of globe intercentroid distance is essential for outcome assessment.

[Prenatal ultrasonic measurements of the eye and the interorbital distance]

OBJECTIVES

The two-fold objective of this study was to ascertain whether the antero-posterior diameter of the fetal eye is comparable to the transversal diameter and to establish nomograms based on the measurements obtained for ocular diameter (OD), mean interorbital distance (MIOD) and the MIOD/biparietal diameter (BPD) ratio related to gestational age. TYPE: A prospective monocentric study based on 398 sonographic fetal eye measurements.

RESULTS

The antero-posterior and transverse ocular diameters of the fetal eye remain comparable throughout pregnancy (R = 0.997, p < 0.0001). They were related to gestational age and BPD. The MIOD/BDP ratio decreased with gestational age. The OD/BPD ratio remained nearly constant. Nomograms were established for OD, MIOD and the MIOD/BPD ratio related to gestational age.

DISCUSSION AND CONCLUSION

The fetal eye can be measured on any diameter provided the sonographic scan for the measurement is flawless. Nomograms and values are given. Hyper- and hypotelorism and microphthalmia can be found in numerous malformative syndromes. Previously published tables are not well-suited to the French population.

Craniometaphyseal dysplasia in six generations of a German kindred

Craniometaphyseal dysplasia (CMD) was found in 6 generations of a large German kindred; 24 affected individuals were identified. The clinical diagnosis was confirmed by further examinations in 15 individuals, including 2 exhumed skeletons. Five deceased individuals were considered to be undoubtedly affected by reviewing photographs, and 4 must have had CMD from genealogical considerations. Pedigree analysis was performed over 8 generations back to persons born at the beginning of the 18th century in a central area of Germany. The trait could be traced back to a common male ancestor, born in 1790. Molecular genetic investigations on 3 generations of this kindred are in progress. In the present study we describe the clinical characteristics of the family.

[Results of surgical therapy of orbital abnormalities]

Dystopies of the bony orbit are caused mainly by craniosynostosis, facial clefts and encephaloceles. This article presents the results of the surgical correction of orbital hypertelorism in 24 patients. Using this operation technique, the bony interorbital distance was decreased from an average of 47.6 mm to 22.8 mm. However, the distance between the soft tissues was not reduced by the same amount as the distance between the bony orbits. The intercanthal distance decreased from an average of 58.5 mm to 44.5 mm, whereby an additional refixation of the medial palpebral ligament resulted in a reduction of the intercanthal distance to 40.8 mm. A strabismus divergens was seen preoperatively in 18 patients, postoperatively only in 8 patients. Four of the latter had to undergo operative correction of the diplopia. We conclude that the operative technique is not reserved only for complex cases of hypertelorism because it shows satisfactory functional and aesthetic results with a low complication rate.

Temporal aspects in craniometaphyseal dysplasia: autosomal recessive type

We present the clinical and radiographic findings in a patient with the autosomal recessive form of craniometaphyseal dysplasia (CMD). The changes from infancy to the age of 17 years are illustrated and discussed.

Rieger's syndrome: a case report

Rieger's syndrome is a rare autosomal-dominant disorder characterized by dental, ocular, and periumbilical abnormalities. Essential ocular features include goniodysgenesis, which leads to increased intraocular pressure and subsequent glaucoma and visual loss. Dental findings include midfacial hypoplasia and the absence of primary and permanent incisors and second premolars. Comprehensive preventive dental care in the form of fluorides and sealants is required, especially in patients with severe hypodontia, to increase the resistance of the remaining teeth to dental caries. This article describes a case of Rieger's syndrome in a 9-year-old child and emphasizes the need for comprehensive oral rehabilitation.

Surgical planning and correction of medial craniofacial cleft

In the framework of malformations that concerns the craniofacial area, the orbit is often involved because it represents the border structure between the neurocranium and the splanchnocranium. In these malformations it is very easy to find hypertelorism. Tessier classified clefts rising from the anterior skullbase and involving the maxilla and the alveolar process, as medial or 0 = 14 clefts. We report on a 2-year-old patient, treated with cranial decompression at an early age, suffering from this kind of malformation. To correct it, the surgical technique of facial bipartition was used. This technique, used for the first time by Tessier and then modified by Stricker and colleagues, allows the simultaneous correction of the orbits and maxilla. It is very important to make a correct diagnosis, to plan for surgery carefully for patients suffering from this kind of pathology, and to prescribe the most effective therapy. A computerized analysis system, based on the study of teleradiographic images and on three-dimensional computed tomography, to quantify the extent of the malformation and to define surgical planning was developed.

Acrocallosal syndrome: a case report

This report describes the case of an 18-month-old Caucasian male infant with clinical and radiological findings indicative of the Schinzel acrocallosal syndrome. He was born to non-consangiuneous parents. His father had been diagnosed with Greig syndrome. The patient underwent surgery for preaxial polysyndactyly of both hands and feet. The similarity to the Greig syndrome is discussed. It is possible that both the acrocallosal syndrome and the Greig syndrome are variant expressions of the same autosomal dominant condition. Surgery may improve thumb opposition and shoe wear.

Qualitative analysis of fetal movement patterns in the Neu-Laxova syndrome

The Neu-Laxova syndrome was diagnosed in a fetus at 34 weeks' gestation on the basis of ultrasonographic qualitative analysis of fetal movement patterns and malformations. The first ultrasound study was performed at 34 weeks' gestation and a dead 960 g female fetus was delivered at 36 weeks' gestation.

Study and planning of the surgical procedure for the orbital district in patients affected by craniofacial malformations

Orbital surgery is of critical importance within the framework of craniofacial surgery. The conical conformation of orbits requires analysis and surgical procedure planning methods involving all three dimensions. We present our protocol for the analysis and our three-dimensional surgical procedure plan to treat orbital malformations using teleradiography and two- and three-dimensional computed tomographic imaging. A number of clinical cases treated according to this approach are also presented.

Fetal face visualization using three-dimensional ultrasonography

Evaluation of the fetal face is an essential part of the sonographic examination for high risk pregnancies. Even under optimal conditions, the complex curvature of the face makes it difficult to obtain adequate images with two-dimensional ultrasonography, and many cross-sectional images are required to obtain a complete impression. The purpose of this paper is to show preliminary work in assessing the utility of three-dimensional ultrasonographic visualization of the fetal face. Fetal facial features were evaluated with three-dimensional sonography by scanning with a volume transducer and compared to conventional two-dimensional ultrasonographic images in 27 fetuses (gestational ages 10 to 39 weeks). Surface rendered three-dimensional sonographic images of the fetal face were obtained in 24 of 27 fetuses. In four cases the upper lip was clearly imaged on three-dimensional ultrasonography when it could not be seen on two dimensional ultrasonography. Information requiring multiple planes with two-dimensional ultrasonography could be demonstrated on a single image from three-dimensional ultrasonography. Images of abnormal faces were seen with both two- and three-dimensional ultrasonography in two cases of cleft lip and one case of holoprosencephaly. Volume data acquisition required approximately 10 sec and reconstruction required approximately 5 sec with instantaneous review of planes through the volume data set. Surface rendering required 2 to 10 min depending on the angular viewing range. Three-dimensional ultrasonography has the potential to provide improved visualization of the fetal face compared with conventional two-dimensional sonographic imaging.

Monobloc and facial bipartition osteotomies: quantitative assessment of presenting deformity and surgical results based on computed tomography scans

PURPOSE

The results of monobloc (MB) or facial bipartition (FB) osteotomies on 23 consecutive patients operated on between 1987 and 1991 were evaluated.

PATIENTS AND METHODS

A previously described method of clinically relevant linear measurements taken from preoperative and postoperative computed tomographic scans of these patients was used to document their presenting dysmorphology and the results of surgical correction initially and 1 year after operation. These data were compared with control values, and a percentage of normal for each measurement was derived for each patient.

RESULTS

In the patients with craniofacial dysostosis undergoing an MB osteotomy, the initial cranial vault length (87% of normal), medial orbital wall length (87%), zygomatic arch length (84%), and extent of globe protrusion (134%) all indicated horizontal (anterior-posterior) deficiency of the upper and middle face. After surgery, these measurements moved closer to age-matched control values. At the 1-year interval a minor degree of relapse was evident. In the patients with craniofacial dysostosis who were believed to need an FB osteotomy, the globe protrusion (142% of normal), medial orbital wall length (85%), and zygomatic arch lengths (83%) all indicated horizontal (anterior-posterior) deficiency in the upper and middle face. In addition, the anterior interorbital distance (123% of normal), mid-interorbital distance (122%), and intertemporal distance (126%) all indicated upper face hypertelorism. As a result of the FB osteotomy, anterior bony projection was achieved, and the hypertelorism was improved, but fell short of age-matched normal values. In the patients with frontonasal dysplasia, cranio-orbital clefting, and isolated orbital hypertelorism who underwent an FB osteotomy, preoperative measurements showed a distinct widening of the whole upper midface with forward projection of the medial relative to the lateral orbital walls. The orbital measurements revealed a substantially widened anterior interorbital distance (175% of normal), increased mid-interorbital distance (123%), and an increased distance between the lateral orbital walls (106%). After the surgical procedure, these measurements were improved and relatively stable but not completely normalized.

CONCLUSION

The use of quantitative measurements in the initial evaluation, intraoperative skeletal reshaping, and assessment of early and late reconstructive results provides useful benchmarks.

Significance of orbital measurements in the fetus

Orbital imaging is not performed routinely during obstetrical sonography, but the discovery of abnormal orbital diameters provides evidence of fetal dysgenesis. This study was designed to establish the validity of a previously developed orbital nomogram for a high-risk population and to determine whether proved cases of hypotelorism and hypertelorism fell outside the normal ranges. Inner and outer orbital measurements of 422 fetuses were obtained prospectively during routine obstetrical sonography in a high-risk patient population. Comparison of these measurements to the previously established nomogram demonstrated that the nomogram is still accurate with current equipment and in a population at high risk for anomalies. In addition, sonograms and autopsy and clinical data from six cases of hypotelorism, two of cyclopia, and three of hypertelorism were reviewed retrospectively. Both inner and outer orbital measurements fell clearly below two standard deviations of the mean in all six cases of hypotelorism. The three cases of hypertelorism had inner orbital measurements above the 95th percentile and outer orbital distances within normal limits but near the 95th percentile. All cases with abnormal orbital distances had associated intra- or extracranial abnormalities, including holoprosencephaly, encephalocele, cleft palate, cardiac anomalies, imperforate anus, diaphragmatic hernia, and digit anomalies.

Frontonasal and craniofrontonasal dysplasia: preoperative quantitative description of the cranio-orbito-zygomatic region based on computed and conventional tomography

The unoperated crano-orbito-zygomatic complex of 18 children (mean 4.7 years) with frontonasal dysplasia (FND) and 12 children (mean 1.1 years) with crainofrontonasal dysplasia (CFND) was quantified by 15 standard measurements performed on either computed tomography scans or facial tomograms. The results were compared with age-matched control values. In the FND group, the mean anterior interorbital and mid-interorbital distances were significantly increased at 148% and 118% of normal, and in the CFND patients, at 177% and 140% of normal. Excessive medial orbital wall protrusion (mean, 145% of normal in FND and 177% in CFND), shortened zygomatic arch lengths (mean, 94% of normal in FND and 91% in CFND), and reduced cephalic lengths (mean, 96% of normal in FND and 83% in CFND) were all observed. An expanded interzygomatic buttress distance was documented only in the CFND group, at 11% of normal. The clinical presentation of craniofacial deformities such as FND and CFND can be objectively described by a numerical analysis of the bony pathology.

Cranio-metaphyseal dysplasia

Cranio-metaphyseal dysplasia in two brothers, aged fourteen and twelve, is reported. Both brothers presented with deafness, repeated episodes of cold and cough and mouth breathing. Striking craniofacial configuration consisted of hypertelorism, prominent glabella and zygomatic arches, mandibular prognathism and overgrowth of middle third of face. Both patients had genu valgum deformity. Low intelligence and poor scholastic performance present in both brothers were attributed to deafness. Radiographic features consisted of obtuse mandibular angle, defective dentition, sclerotic frontal sinuses, sclerotic mastoids and temporal bones. Splaying of metaphyses of long bones was associated with mild sclerosis. Mild degree of widening of ribs was also present. One brother also had hallux valgus deformity. The radiographic and clinical differentiation of cranio-metaphyseal dysplasia and metaphyseal dysplasia (Pyle's disease) is highlighted.

X-linked recessive inheritance of dysgenesis of corpus callosum in a Chinese family

This report describes a new syndrome of dysgenesis of corpus callosum with other anomalies, presenting as microcephaly, mental retardation, spasticity, and unusual facial appearance in 2 Chinese brothers and their maternal cousins. To date, there has not been any case reported in the Chinese population of this syndrome. All 4 patients in this report present with the same unusual face. Hydrocephalus and/or interhemispheric cyst were found among them. This syndrome is transmitted as an X-linked trait. The nosology is reviewed and discussed.

Crouzon syndrome: prenatal ultrasound diagnosis by binocular diameters

This is a report of second-trimester prenatal diagnosis of Crouzon syndrome suggested by binocular and interorbital diameter measurement and family history. Early prenatal diagnosis provides the option of termination or optimal postnatal management for families who choose to continue the pregnancy.

High-energy orbital dislocations: the possibility of traumatic hypertelorbitism

In a 4-year period from 1983 to 1987, 7160 patients with blunt injuries were admitted to the Maryland Institute of Emergency Medical Services Systems Shock Trauma Center. Facial injuries occurred in 10 percent of this population. High-energy fractures (characterized by computed tomography) were seen in approximately 10 percent of these patients. In this high-energy group, five cases of high-energy orbital dislocations, some representing examples of traumatic hypertelorbitism, were observed. They represent 1.5 percent of the 342 midface fractures observed and 4.8 percent of the naso-orbital ethmoid fractures observed (105 patients). One additional patient is described who was seen at the UCLA Medical Center for late repair of the condition. High-energy impacts of the upper midface created fractures of both orbits, zygomas, and nasoethmoidal regions permitting lateral transposition, enlargement, and divergence of the orbits. Interorbital, intercanthal, and interpupillary distances were increased, criteria that confirm the diagnosis of hypertelorbitism. Fifty percent of the patients were bilaterally blind, and one patient sustained unilateral blindness.

[Ultrasonographic diagnosis of developmental facial defects in fetuses]

Findings of 55 ultrasound examinations have been evaluated in 35 fetuses with various facial malformations detected by ultrasound and confirmed at birth. Ultrasonographic presentations and diagnostic criteria are given for major facial, palate and lip clefts, abnormal nasal shape, hypo and hypertelorism, microphthalmia, exophthalmia, micro and macrogenia, macroglossia. Ultrasonography proves to be a highly revealing diagnostic study with the provision of a good structural visualization and physicians' skill.

Computerized tomographic analysis of orbital hypertelorism repair: spatial relationship of the globe and the bony orbit

Computerized tomographic scans provide a new means of evaluating the spatial and geometric relationships between the movement of the bony orbit and its soft tissue contents (the globe and extraocular muscles) [1, 12]. Preoperative and postoperative computerized tomographic scans were analyzed in four patients to explore these relationships. Measurement of the changes in distance between the globes correlated most closely with the change in the distance between the lateral orbital walls; resection of medial (inter-orbital) bone provides space into which the globe is translocated. The medial rectus muscle may be bowed across the medial wall osteotomy line, creating a functional shortening of the muscle; this finding may explain the esotropia that is commonly seen after this procedure [2, 3]. These observations should have a direct impact on the understanding and planning of orbital hypertelorism correction.

Orbital reconstruction in hypertelorism

Orbital hypertelorism as defined by increased bony interorbital distance is a complex manifestation of many congenital anomalies. As such, it is associated with a multitude of orbital, adnexal, and surrounding soft-tissue deformities. Treatment of these problems requires extensive experience and a comprehensive team, permitting adequate preoperative evaluation, diagnosis, and treatment. The results obtained may be dramatic. The overall safety of the procedures has been demonstrated. Continued refinements and long-term follow-up will undoubtedly continue to make significant improvements.

[3-dimensional display of computed tomographic studies of craniofacial anomalies]

Craniofacial anomalies are conventionally investigated by cephalometry using ordinary radiographs and by computed tomography. Both methods have the major disadvantage of trying to demonstrate a complex three-dimensional structure, such as the skull, in two dimensions and they therefore cannot display a true spatial image. We present the principle underlying a three-dimensional display derived from computer tomographic studies and discuss the clinical application in the diagnosis of craniofacial anomalies.

CT in the evaluation of the orbit and the bony interorbital distance

The distance between the orbits and their individual dimensions are important in the diagnosis of craniofacial anomalies. Most observers rely on standard radiographs for measuring the bony interorbital distance. Tomography of the skull base and orbital computed tomography (CT) can also be used. This article describes the normal range of the bony interorbital distance and other useful orbital linear and angular measurements as determined from a series of CT scans of the orbits in 400 adults who had CT for other purposes. The normal interorbital distance measured at the posterior border of the frontal processes of the maxilla on nonrotated scans, in the plane of the optic nerve, ranges from 2.29 to 3.21 cm (average, 2.67 cm) in men and 2.29 to 3.20 cm (average, 2.56 cm) in women. The widest interorbital distance lies behind the posterior poles of the globes. This ranges from 3.16 to 4.10 cm (average, 3.37 cm) in men and 2.93 to 3.67 cm (average, 3.20 cm) in women.

Uncomplicated trigonocephaly. A radiographic affirmation of conservative therapy

Trigonocephaly is a relatively rare deformity of the skull characterized by triangular prominence of the bones of the forehead and orbital hypotelorism. Long-term results in a group of patients with clinical and radiographic follow-up are analyzed, the radiographic findings reviewed, and possible etiologies discussed. The etiologic relationship between premature synostosis of the metopic suture and trigonocephaly is questioned. Uncomplicated trigonocephaly is a self-limited, self-correcting deformity, and a normal cosmetic appearance develops without surgical treatment. Surgical craniectomy as treatment for uncomplicated trigonocephaly is not indicated on the basis of the authors' experience.

Transsphenoidal meningocele with hypothalamic insufficiency

A 16-year-old girl with transsphenoidal meningocele and signs of hypothalamic insufficiency is presented. Hormonal disturbances have been reported in only three similar cases in the literature. The radiological criteria for the diagnosis are discussed with emphasis on the differential diagnosis of a persistent cranipharyngeal canal. Based on the present case and studies of the pertinent literature we propose that all patients exhibiting signs of dysraphism of the base of the skull should be thoroughly investigated for hormonal disturbances. Children with cleft palate should be examined for possible concomitant dysraphism of the skull.