Sick sinus syndrome diagnosed after a sinus arrest during treatment for zygomatic fracture: a case report

BACKGROUND

Intraoperative sinus arrest is rarely seen during zygomatic fracture treatment. The patient was diagnosed with sick sinus syndrome based on repeated postoperative sinus arrest, which could have resulted in death if diagnosed late, making this case very significant to report.

CASE PRESENTATION

Sick sinus syndrome is an arrhythmia associated with reduced automaticity of the sinoatrial node or impaired sinoatrial node conduction. We report the case of a 67-year-old man diagnosed with the syndrome after a sinus arrest that occurred during a zygomatic fracture treatment. The patient had cheek pain and mouth opening disorder, dizziness after fainting and sustaining a facial injury. Preoperative examination determined that the syncope was due to drug-induced arrhythmia, and surgery was authorized after drug withdrawal. During the operation, sinus arrest was observed due to trigeminal vagal reflex, and heart rate was restarted by stopping the operation and chest compressions. After the surgery, the patient showed symptoms of dizziness and palpitations, and sinus arrest following atrial fibrillation and supraventricular tachycardia, which was diagnosed as sick sinus syndrome, and a pacemaker was implanted. Currently, 8 years have passed since the surgery, and there are no symptoms of mouth opening disorder, dizziness, or palpitations.

CONCLUSIONS

In the case of maxillofacial injuries due to syncope, cardiogenic syncope is a possibility, and repeated syncope is a risk for death due to delayed diagnosis. There are no reports of maxillofacial trauma leading to a diagnosis of sick sinus syndrome. The purpose of this case report is to disseminate the importance of diagnosing the cause of syncope as well as injury treatment.

Expert Consensus on Navigation-guided Unilateral Delayed Zygomatic Fracture Reconstruction Techniques

The zygoma is located in the medial and lateral parts of the face, supporting the midfacial contour. The forward projection of the zygoma and the zygomatic arch often expose them to injury. Fractures of the zygoma can lead to the displacement of the zygoma and the zygomatic arch, causing facial collapse deformity. For delayed zygomatic fractures, the loss of normal anatomical landmarks caused by the malunion of the fracture lines and remodelling of the bony contour makes it difficult to determine the correct positions of the zygomatic bones. In such cases, ideal and steady outcomes with satisfactory midface symmetry have been difficult to obtain using traditional surgical methods. Nowadays, the application of digital surgical software and surgical navigation helps surgeons to perform accurate preoperative simulations to obtain ideal three-dimensional virtual surgical plans and achieve accurate reduction by intraoperative navigation systems, which increase the accuracy and predictability of fracture reduction outcomes. Experts from the Society of Oral and Maxillofacial Surgery, Chinese Stomatological Association have fully discussed and formulated an expert consensus on navigation-guided unilateral delayed zygomatic fracture reconstruction techniques to standardise the clinical operation procedures and promote the application.

Single-Point Fixation for Noncomminuted Zygomaticomaxillary Complex Fractures-A 20-Year Experience

PURPOSE

Zygomaticomaxillary complex (ZMC) fractures occur often. However, no clinical consensus has been reached regarding the number of fixation points required when performing open reduction and internal fixation (ORIF). The objective of the present study was to explore the utility of single-point fixation in the management of noncomminuted ZMC fractures.

PATIENTS AND METHODS

We analyzed the data from a retrospective case series of 211 patients treated during a 20-year period.

RESULTS

The mean length of follow-up was 3.4 months. Of the 211 patients, 162 with noncomminuted ZMC fractures had been treated with single-point fixation of the zygomaticomaxillary buttress. During the follow-up period, 1 patient experienced tooth loss because of a root present in the fracture line, 7 experienced intraoral plate exposure, with 2 subsequently undergoing plate exchange, and 8 developed a wound infection. No patients required orthognathic surgery or cheek implants for malar asymmetry. No patient developed hypoglobus or enophthalmos, and none required revision ORIF of their ZMC fracture.

CONCLUSIONS

To the best of our knowledge, the present study represents the largest series in the literature reporting the surgical results and outcomes of patients with noncomminuted ZMC fractures treated with single-point fixation. In experienced hands, we believe this is a viable surgical option if appropriate surgical considerations are made.

Epidemiology of maxillofacial trauma in the elderly: A European multicenter study

INTRODUCTION

The progressive aging of European population seems to determine a change in the epidemiology, incidence and etiology of maxillofacial fractures with an increase in the frequency of old patients sustaining craniofacial trauma. The objective of the present study was to assess the demographic variables, causes, and patterns of facial fractures in elderly population (with 70 years or more).

MATERIALS AND METHODS

The data from all geriatric patients (70 years or more) with facial fractures between January 1, 2013, and December 31, 2017, were collected. The following data were recorded for each patient: gender, age, voluptuary habits, comorbidities, etiology, site of facial fractures, synchronous body injuries, Facial Injury Severity Score (FISS).

RESULTS

A total of 1334 patients (599 male and 735 female patients) were included in the study. Mean age was 79.3 years, and 66% of patients reported one or more comorbidities. The most frequent cause of injury was fall and zygomatic fractures were the most frequently observed injuries. Falls were associated with a low FISS value (P<.005). Concomitant injuries were observed in 27.3% of patients. Falls were associated with the absence of concomitant injuries. The ninth decade (P<.05) and a high FISS score (P<.005) were associated with concomitant body injuries too.

CONCLUSIONS

This study confirms the role of falls in the epidemiology of facial trauma in the elderly, but also highlights the frequency of involvement of females, and the high frequency of zygomatic fractures.

[A retrospective analysis of 621 cases with craniomaxillofacial fractures]

PURPOSE

To investigate the epidemiological characteristics of 621 hospitalized patients with craniomaxillofacial fractures by a retrospective study.

METHODS

From July 2015 to August 2016, the medical records of 621 patients with craniomaxillofacial fractures in Shanghai Ninth People's Hospital were analyzed statistically according to age, gender, etiology and site of fracture. Chi-square test was used to analyze the causes of single and multiple fractures with SPSS 20.0 software package.

RESULTS

The male to female ratio was 2.18: 1. The average age was 34.7±15.5 years with 19-29 years old group accounted for the most (28.3%). Traffic accident was the top cause of injury (49.0% ); There were 319 cases of orbital fractures (51.4%), followed by 292 cases of zygomatic complex (47.0%) and 247 cases of mandibular fractures (39.8%).

CONCLUSION

The quantity and location of fractures are related to the cause of injury, the nature of stress and anatomical structure of corresponding areas. Establishing a sound system of traffic accident management and related laws is an urgent problem to be solved.

Surgical approach to isolated bilateral orbital floor fractures

Isolated bilateral orbital floor fractures are uncommon and are rarely described in the scientific literature. They are usually seen in association with naso-ethmoidal fractures, zygomatic fractures, or fractures of the middle third. We report our experience in the management of a patient presenting bilateral isolated orbital floor fracture. The difficulties in management of these fractures are due to the lack of an uninjured contralateral side for intraoperative comparison.

[Application of computer-assisted navigation in oral and maxillofacial surgery: retrospective analysis of 104 consecutive cases]

PURPOSE

To evaluate the application of computer-assisted navigation system (CANS) in Oral and Maxillofacial Surgery.

METHODS

One hundred and four patients were included in this study, including 34 with zygomatic-orbital-maxillary fracture, 27 with unilateral TMJ ankylosis, 29 with fibrous dysplasia, 9 with mandibular angle hypertropia, 3 with cartilage and bone tumors and 2 with facial foreign bodies. CT scan was performed and the data was saved as Dicom (digital imaging and communications in medicine) format. With preoperative planning and 3-dimensional simulation, normal anatomic structures of the affected side were created by superimposing and mirroring the unaffected side. The osteotomy lines, amount and range of resection, the reduction position of bony segments and the reconstruction morphology was determined and displayed. All surgeries were performed under the guidance of navigation system. The accuracy of navigation was evaluated by comparing the postoperative CT three-dimensional model with preoperative surgical planning.

RESULTS

Through registration, an accurate match between the intra-operative anatomy and the CT images was achieved. With the guidance of navigation, anatomic structures and the position of surgical instruments were shown real-time on the screen. No complications occurred in all patients and the systematic error was within 1 mm. Good coincidence with preoperative planning was achieved for osteotomy lines, the amount of resection and reduction of fractures. The mean error between virtual and real results was (1.46±0.24) mm. All patients healed uneventfully and facial symmetry was improved.

CONCLUSIONS

With the ability of preoperative planning, surgical simulation and postoperative prediction, CANS shows its great value in improving the accuracy of oral and maxillofacial surgery, reducing trauma and restoring facial symmetry. It is regarded as a valuable and safe technique in this potentially complicated procedure.

[Clinical application of mimics software in three dimensional CT images for treatment of zygomatic complex fracture]

OBJECTIVE

To study a reliable CT measuring method for quantitative diagnosis of unilateral zygomatic complex fracture and operation guiding.

METHODS

20 zygomatic complex fracture patients needed operation were collected, three dimensional CT images of all patients were measured and analyzed by Mimics software before operation. Standard anatomy points of bilateral zygomatic complex and adjacent bone were selected, then the distance of two same selected points and the angles of three same selected points were measured by Mimics software. Compared to uninjured side, the different value of the distance and the angle of injured side zygomatic complex were acquired, zygomatic complex fractures were operated based on the different value. All patients were examined by three dimensional CT postoperatively, and the different value of the distance and the angle of both side were measured using same method to pre-operation. Therapy effects were analyzed based on the data of different value of the distance and the angle.

RESULTS

1) The displacement of zygoma of most patients was backward and inward. The different value of the distance between uninjured and injured side was less than 2 mm, and the different value of the angle was less than 1 degrees. All patients reached the three-dimensional symmetric, surgical results were satisfactory in recovery of occlusion and mouth opening. 2) The zygomatic arch protrusion angle was about 138.50 degrees +/- 1.15 degrees, zygomatic prominent angle was about 132.72 degrees +/- 0.89 degrees. The two data were normal distribution.

CONCLUSION

Three dimensional CT measurements of zygomatic complex can be achieved for the quantitative measurement of spatial displacement, and have directive significance for the reduction of the zygomatic complex fractures.

[Clinical application of self-regulating exterior bracket for zygomatic fracture]

PURPOSE

To investigate the clinical value of self-regulating exterior bracket for zygomatic fracture.

METHODS

Thirty patients with unilateral zygomatic fracture were treated using self-regulating exterior bracket. They all had limitation of mouth opening and facial collapse. 1.5 cm incision was made from the distal upper first molar. After reducting to normal mouth opening and symmetrical face, self-regulating external bracket was used to fix the fracture for 3 weeks.

RESULTS

After removing the self-regulating bracket, X-ray showed the fracture healing well. The patients had normal mouth opening.

CONCLUSION

The clinical effect of using self-regulating bracket to fix fracture after reduction for unilateral zygomatic fracture is good, it is a simple surgical method.

[Clinical study of internal rigid fixation of zygomatic fracture through percutaneous minimally invasive approach]

PURPOSE

To evaluate the efficacy of internal rigid fixation of zygomatic fracture through percutaneous minimally invasive approach.

METHODS

Three hundred and forty-two cases of zygomatic fractures were selected from June 2003 to 2009, using Zingg classification,all cases were divided into three groups and were treated by internal rigid fixation through percutaneous minimally invasive access.

RESULTS

Nineteen patients had infection, the other patients had primary healing. All patients got symmetrical facial contour, the fractured bone segments integrated well on computed tomograph scan, the facial scars were minimal.

CONCLUSION

Percutaneous minimally invasive access for internal rigid fixation of zygomatic fracture produces minimal injury, inconspicuous facial scars, fewer complications, and is an ideal way for management of zygomatic fracture.

[The application of lateral brow incision by the guide of sphenozygomatic suture for zygomatic complex fracture]

PURPOSE

To explore the application of lateral brow incision by the guide of sphenozygomatic suture for zygomatic complex fracture.

METHODS

Lateral brow incision combined with intraoral vestibule incision and below cilia incision were applied in 26 patients who had Zingg's type B and C zygomatic complex fracture,through which the fracture lines around the forehead and zygomatic suture, sphenozygomatic suture, suborbital edge, zygomatic maxillary suture, zygomatic temporal suture, zygoma- alveolar column were exposed. After accurate reduction by the guide of sphenozygomatic suture, rigid fixation by titanium plates was performed. The patients were followed up for 3-24 months.

RESULTS

Twenty-three patients acquired satisfactory outcome with ideal facial figure,function and minimal scar and 3 patients of type C developed mild asymmetric facial contour.

CONCLUSIONS

The application of lateral brow incision by the guide of sphenozygomatic suture and rigid fixation for zygomatic complex fracture approach leaves minimal scar and injury to the facial nerve,with better esthetic and functional outcome.

[Treatment of zygomatio- orbital fractures with small local incisions: report of 32 cases]

PURPOSE

To evaluate the surgical result of small local incisions in the treatment of zygomatio-orbital fractures.

METHODS

32 patients with zygomatio-orbital fractures were operated on with two or more kinds of incisions, including subciliary incision, lateral eyebrow incision, transverse incision along the superior margin of zygomatic arch, oral vestibular incision, maxillary sinus incision, the original wound according to the area and type of the fractures. The fracture line was exposed via the small local incisions and fixed with micro-titanium plates. The therapeutic effectiveness was evaluated 3 to 6 months after operation.

RESULTS

All patients had primary healing without apparent scars in the face,except that one patient developed mild ectropion and two had temporary paralysis of the temporal branches of the facial nerve. The function of the eyes recovered completely, while the jaw movement improved significantly. The facial appearance recovered to normal height and width and the bilateral face became symmetrical.

CONCLUSION

Treatment of zygomatic-orbital fractures with small local incisions is minimally invasive and the facial appearance and function can be recovered significantly with few complications.

[An alternative method for the correction of enophthalmos: deep lateral orbital approach]

Both increased orbital volume due to inadequate orbital floor reconstruction and loss of orbital volume may result in enophthalmos. Enophthalmos, vertical dystopia, and "lateral scleral show" deformity were detected in a 33-year-old female patient who presented with periorbital deformities after three operations for the correction of traumatic zygomatic fracture. First, vertical dystopia was repaired by reinforcing the orbital base with cranial bone grafting. Since enophthalmos was not successfully corrected, orbital volume augmentation was performed using the deep lateral wall through an upper eyelid crease incision. The only postoperative complaint was edema which was controlled by application of ice.

[Healing of zygomatic arch fractures in rats with lesions of the median hypothalamic eminence]

The purpose of this study was to verify the effect of hypothalamic median eminence lesion on healing process in fracture of anterior portion of zygomatic arch, in rats, by histologic evaluation. The animals were killed in number of 5 for each periods at 6, 12, 24 and 36 days post-lesion. Our results showed morphologic changes and tinctorial in all considered periods, with more evidence at 12 and 24 days post-fracture and evidents signals of hipomineralization. This disfunction appeared only after a mean period of 12 days post-lesion.

Traumatic rupture of the thoracic aorta during pregnancy. Surgical considerations

This is a report of successful management of a traumatic rupture of the thoracic aorta in pregnancy. Both mother and daughter are alive and well 24 months after the injury. The various aspects of the surgical and supportive treatment are discussed.

Blindness without direct injury to the globe: a complication of facial fractures

Two cases of bilateral told blindness, resulting from fractures of the middle third of the face without direct trauma to the globe, are reported. The mechanism of such blindness is discussed, and the literature on it is reviewed.

[Viewpoints on primary and secondary treatment in orbital fractures]

The orbit is frequently involved in fractures of the middle part of the face. In order to maintain optimum functioning of the eyeball after healing of the fracture, anatomically correct reconstructioning is indicated as early as in primary treatment. In those cases where this is not possible, a secondary treatment is required which should be carried out in cooperation with the ophthalmologist.