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Le Roux MK, Thollon L, Godio-Raboutet Y, Carbonnel E, Guyot L, Graillon N, Foletti JM. The association of Le Fort midfacial fractures with frontobasal injuries: a 17-year review of 125 cases, reflections on biomechanics, classifications and treatment. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2020; 122:561-565. [PMID: 33035710 DOI: 10.1016/j.jormas.2020.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
The frequency of midface and frontobasal fractures has increased over the past 40 years despite the improvement and stringent regulation implemented on modern safety equipment (belts, helmets…). This observation might be correlated with the progress of radiodiagnosis tools. Literature was reviewed according to Prisma guidelines. We searched for reviewed articles, published between January 2000 and December 2017, through Medline (Pubmed) online databases and ScienceDirect, using the following MeSH Keywords: "Le Fort classification", "Le Fort fracture", "Frontobasal fracture", "skull base fracture", "Midface Fractures". Among 652 patients with frontobasal fractures, 125 (19.1%) were associated with a Le Fort fracture. 59 (9%) were associated with Le Fort III fracture, 51 (7.8%) with Le Fort II fracture and 15 (2.3%) with Le Fort I fracture. When frontobasal fractures were associated with midfacial fractures, we found 18 cerebrospinal fluid leaks (11.8 %) and 19 cases of meningitis (12.5 %). When only the frontobasal area was involved, there were 6 cerebrospinal fluid leaks (4.3 %) and 6 meningitis (4.3 %). Our results highlight a regular association between Le Fort fractures and frontobasal fractures for stages II and stage III of Le Fort fractures and also found a higher rate of neuro-septic complication. Further research shall investigate treatment and monitoring recommendations fitting modern epidemiology of craniofacial traumatology.
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Affiliation(s)
- Marc-Kevin Le Roux
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France.
| | - Lionel Thollon
- Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | | | - Emeric Carbonnel
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
| | - Laurent Guyot
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France
| | - Nicolas Graillon
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France
| | - Jean-Marc Foletti
- Surgery Department Maxillofacial and Stomatology of Pr Chossegros. CHU Conception, 147 Boulevard Baille, 13005 Marseille. France; Aix Marseille University, SPMC EA 3279, Jardin du Pharo - 58, Boulevard Charles Livon, 13284 Marseille Cedex 07, France; Aix-Marseille Univ, Univ Gustave Eiffel, LBA, Marseille, France
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Douglas J, Gill K, Holmes S. Combining trauma severity indices to create a unified craniofacial disruption index: addition of the frontobasal unit to the ZS model. Br J Oral Maxillofac Surg 2020; 58:784-788. [DOI: 10.1016/j.bjoms.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/02/2020] [Indexed: 11/25/2022]
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Adeleye AO, Malomo TA. Titanium Clamps for a Simple Low-Profile Autologous Osteosynthesis in the Reconstruction of Posttraumatic Craniofacial Convexital Skeletal Disruption. Craniomaxillofac Trauma Reconstr 2017; 10:29-34. [PMID: 28210405 DOI: 10.1055/s-0036-1592096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/15/2016] [Indexed: 10/20/2022] Open
Abstract
Attempts at reconstruction of posttraumatic craniofacial defects (PTCDs) can be a challenge in low-resource practice areas of the world where the needed biomaterials are logistically beyond reach. A simple low-profile technique of autologous osteosynthesis for PTCD using the titanium clamps is presented in this report. In addition, a 6-year prospective database on a consecutive cohort of patients who underwent this procedure was analyzed for clinical, functional, and aesthetic outcomes, both in-hospital and at midterm follow-up. The clinical data of 18 patients, all males, mean age 31.3 years (standard deviation, 9.7), were analyzed. Road traffic accidents (RTAs) were the cause of trauma in 14 of 18 patients (78%) and motorcycle crash, none helmeted, in 10 of the 18 patients (71% of RTAs). Out of 18 cases, 17 were open fractures; 89% suffered mild head injury, and associated brain injury on CT scan included pneumocephalus in 6 (5 of them significant); acute extradural hematoma in 4 and subdural in 2, and brain contusions in 9. The surgery was successful in all the cases: operative time <3 hours in 10 cases (56%), the in-hospital outcome was good in 95%. The median follow-up time was 24 months, in 6 of the 18 cases for ≥36 months. There was no case of surgical site infection in the perioperative or the follow-up period to date. The aesthetic outcome was also acceptable. This surgical technique for the reconstruction of PTCD appears effectual. Although its low cost makes it very attractive therein, it appears to be actually also recommendable even outside the low-resource developing countries.
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Affiliation(s)
- Amos Olufemi Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, and University College Hospital, UCH, Ibadan, Nigeria
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Single-Stage Surgical Reconstruction of Posttraumatic Compound Complex Fronto-Basal Cranial Vault Fracture in a Resource-Limited Practice. J Craniofac Surg 2016; 27:1302-5. [DOI: 10.1097/scs.0000000000002791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Huempfner-Hierl H, Bohne A, Wollny G, Sterker I, Hierl T. Blunt forehead trauma and optic canal involvement: finite element analysis of anterior skull base and orbit on causes of vision impairment. Br J Ophthalmol 2015; 99:1430-4. [PMID: 26089215 DOI: 10.1136/bjophthalmol-2015-306646] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/04/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Clinical studies report on vision impairment after blunt frontal head trauma. A possible cause is damage to the optic nerve bundle within the optic canal due to microfractures of the anterior skull base leading to indirect traumatic optic neuropathy. METHODS A finite element study simulating impact forces on the paramedian forehead in different grades was initiated. The set-up consisted of a high-resolution skull model with about 740 000 elements, a blunt impactor and was solved in a transient time-dependent simulation. Individual bone material parameters were calculated for each volume element to increase realism. RESULTS Results showed stress propagation from the frontal impact towards the optic foramen and the chiasm even at low-force fist-like impacts. Higher impacts produced stress patterns corresponding to typical fracture patterns of the anterior skull base including the optic canal. Transient simulation discerned two stress peaks equalling oscillation. CONCLUSIONS It can be concluded that even comparatively low stresses and oscillation in the optic foramen may cause micro damage undiscerned by CT or MRI explaining consecutive vision loss. Higher impacts lead to typical comminuted fractures, which may affect the integrity of the optic canal. Finite element simulation can be effectively used in studying head trauma and its clinical consequences.
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Affiliation(s)
- Heike Huempfner-Hierl
- Department of Oral & Maxillofacial Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
| | - Alexander Bohne
- Department of Oral & Maxillofacial Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
| | - Gert Wollny
- Biomedical Imaging Technologies, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Ina Sterker
- Department of Ophthalmology, Leipzig University Hospital, Leipzig, Germany
| | - Thomas Hierl
- Department of Oral & Maxillofacial Plastic Surgery, Leipzig University Hospital, Leipzig, Germany
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Awadalla AM, Emara S, Elkammash T, Nablsi H, Sief K. Immediate single-stage reconstruction of complex frontofaciobasal injuries: Part II. Br J Neurosurg 2015; 29:419-24. [PMID: 25686654 DOI: 10.3109/02688697.2015.1006169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The purpose of this prospective study was to identify selection criteria for immediate single-stage reconstruction in patients with severe complex craniofacial trauma to improve their functional outcome and reduce complications. PATIENTS AND METHODS In this series, 24 new patients (16 men and 8 women) were added to our previous group (26 patients) with an age range from 10 to 55 years with mean of 26 years and Glasgow Coma Scale scores of 5-13; all patients had a combined single-stage repair of their complex craniofacial injuries within 6 h of their admission. We added some modifications to our standard technique using three-dimensional computed tomography, intracranial pressure monitoring, and support of dural repair/graft using dural patch and glue. The esthetic facial outcome was evaluated by an independent plastic assessor based on objective scale criteria. This series was carried out in Prince Salman Military Hospital between November 2010 and September 2013. RESULTS Early neurosurgical outcome was considered good in 22/24 patients (92%), moderate in one patient (4%), and poor in the last one (4%). At late evaluation, 20 cases (83%) regained their consciousness without any cognitive deficit. One patient (4%) remained in neurovegetative status. Early esthetic outcome was considered to be excellent in 18/24 patients (75%), good in 3 patients (12.5%), deemed fair in 2 patients (8%), and labeled poor in only 1 patient (4%). At late evaluation, the patient labeled fair had improved to good with topical scar management and the patient deemed poor had improved to fair with two successive plastic procedures. Complications included a cerebrospinal fluid leak in 2 patients (8%), one was managed conservatively and the second was treated surgically with intra- and extradural grafting. CONCLUSION In complex frontofaciobasal injuries, successful facial repair depends on immediate and definitive reconstruction. However, improved neurological outcomes in these patients depend on judicious selection of the appropriate candidates from severely head-injured patients.
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Affiliation(s)
- Akram M Awadalla
- Department of Neurosurgery, School of Medicine, Zagazig University, Egypt and Prince Salman Military Hospital , Tabouk , Saudi Arabia
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Awadalla AM, Ezzeddine H, Fawzy N, Saeed MA, Ahmad MR. Immediate single-stage reconstruction of complex frontofaciobasal injuries: part I. J Neurol Surg B Skull Base 2014; 76:108-16. [PMID: 25844296 DOI: 10.1055/s-0034-1389371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 06/13/2014] [Indexed: 10/24/2022] Open
Abstract
Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.
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Affiliation(s)
- Akram Mohamed Awadalla
- Department of Neurosurgery, Zagazig University, Zagazig, Sharkia Ap-125, Egypt ; Department of Neurosurgery, King Abdl-Azizi Specialist Hospital, Taif, Saudi Arabia
| | - Hichem Ezzeddine
- Department of Faciomaxillary, King Abdl-Aziz specialist center-KSA, Taif, Saudi Arabia
| | - Naglaaa Fawzy
- Department of Radiodiagnosis, King Abdl-Aziz specialist center-KSA, Taif, Saudi Arabia
| | - Mohammad Al Saeed
- Department of General Surgery, Trauma Unit, King Abdl-Aziz Specialist Center, Taif, Saudi Arabia
| | - Mohammad R Ahmad
- Department of General Surgery, Plastic and Reconstructive Surgery Unit, Zagazig University, Zagazig, Sharkia Ap-130, Egypt
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Ong HS, Qatarneh D, Ford RL, Lingam RK, Lee V. Classification of orbital fractures using the AO/ASIF system in a population surveillance cohort of traumatic optic neuropathy. Orbit 2014; 33:256-62. [PMID: 24694248 DOI: 10.3109/01676830.2014.900087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE In our prospective nationwide surveillance study of traumatic optic neuropathy (TON) in the United Kingdom, the prevalence of orbital fractures was found to be 39% (47/121). The prevalence of skull fractures was 7.4% (9/121). This study aims to identify the association of craniofacial-orbital fractures with the severity of visual loss. METHODS TON patients who sustained orbital fractures were identified prospectively by population-based active surveillance through the British Ophthalmic Surveillance Unit over a 2-year period. Available CT scans were classified by a head and neck radiologist according to the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) scheme: the face was divided into 4 units; fractures in each unit were graded according to displacement (A-C) and severity (1.1-3.3). Correlation between severity of craniofacial orbital fractures and visual acuity as well as number of fractured units and visual acuity were evaluated. RESULTS Twelve of the 25 patients (48%) with imaging available had adequate high resolution craniofacial CT imaging for review and classification using the AO/ASIF system (i.e. 48 classifiable units). Three of 48 (6%) units were undisplaced (grade A), 18 of 48 (29%) units were minimally displaced (grade B), and 4 of 48 (8%) units had largely displaced (grade C) fractures. Twenty-three units (47.9%) had no fractures; 5 patients had radiological evidence of optic canal fractures. Poor visual acuities positively correlated with severity of fractures graded using the AO/ASIF classification (Spearman's rho = 0.95, p = 0.05) and number of fractured units (Spearman's rho = 1.0, p < 0.0001). CONCLUSION AO/ASIF classification system provides a uniform method in the assessment of orbital fractures which correlates with visual outcome in TON.
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Affiliation(s)
- Hon Shing Ong
- Central Eye Services, Central Middlesex Hospital, North West London Hospitals NHS Trust , London NW10 7NS , United Kingdom and
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Abstract
PURPOSE OF REVIEW The management of nasoethmoid or naso-orbito-ethmoid (NOE) fractures requires a thorough knowledge of the central facial anatomy, surgical techniques, available tools and patient factors to obtain optimal restoration of aesthetic form and function. This review article describes the current methods of NOE fracture diagnosis, classification, surgical techniques and complication management, with a review of the current literature published over the past 18 months. RECENT FINDINGS Advanced imaging modalities, bioabsorbable versus titanium rigid fixation, nasolacrimal duct stenting, NOE fracture management in children and the elderly, and novel techniques of medial canthopexy. SUMMARY The treatment of NOE fractures has not changed dramatically in the last 5 years. Advanced surgical techniques, intraoperative computed tomography and absorbable plating hold promise requiring future research prior to broad implementation.
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Perheentupa U, Mäkitie AA, Karhu JO, Koivunen P, Blanco Sequieros R, Kinnunen I. Frontobasilar fractures: proposal for image reviewing algorithm. J Craniomaxillofac Surg 2014; 42:305-12. [PMID: 24525027 DOI: 10.1016/j.jcms.2013.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 05/24/2013] [Accepted: 05/27/2013] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface. MATERIAL AND METHODS The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports. RESULTS The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed. CONCLUSIONS Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.
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Affiliation(s)
- Ulla Perheentupa
- Department of Otolaryngology - Head and Neck Surgery (Head: Prof. Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI-20521 Turku, Finland.
| | - Antti A Mäkitie
- Department of Otolaryngology - Head and Neck Surgery, Helsinki University Central Hospital and University of Helsinki, Finland; School of Science, Department of Industrial Engineering and Management, BIT Research Centre, Aalto University, Finland
| | - Jari O Karhu
- Department of Radiology, Turku University Hospital and University of Turku, Finland
| | - Petri Koivunen
- Department of Otolaryngology - Head and Neck Surgery, Oulu University Hospital and University of Oulu, Finland
| | | | - Ilpo Kinnunen
- Department of Otolaryngology - Head and Neck Surgery (Head: Prof. Reidar Grénman), Turku University Hospital and University of Turku, P.O. Box 52, FI-20521 Turku, Finland
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Post-traumatic morbidity is frequent in children with frontobasilar fractures. Int J Pediatr Otorhinolaryngol 2012; 76:670-4. [PMID: 22370240 DOI: 10.1016/j.ijporl.2012.01.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity. METHODS A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger. RESULTS The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae. CONCLUSIONS Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.
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Abstract
The role of ENT surgery in the management of anterior skull base defects has become increasingly important in recent years. Transnasal endoscopic surgical techniques and intraoperative navigation enable a minimally invasive approach in a large proportion of patients, thus helping to avoid morbidity typically associated with neurosurgical subfrontal approaches. Whereas traffic accidents and sport injuries are the main causes of anterior skull base trauma in the civilian setting, penetrating injuries caused by gunshots and improvised explosive devices (IEDs) play an increasing role in the military arena and terroristic attacks. Minor injuries to the anterior skull base are usually managed by ENT surgeons. Major injuries, involving the midface or neurocranium, require an interdisciplinary approach including maxillofacial surgeons and neurosurgeons. A centre for head and neck medicine and surgery is an ideal setting for such interdisciplinary teams to provide appropriate care for patients with complex skull base trauma in cooperation with ophthalmologists and interventional neuoradiologists. The present article describes concepts for the treatment of anterior skull base trauma established at the head, neck and skull base center at the Ulm military hospital in Germany.
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Affiliation(s)
- K J Lorenz
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Deutschland.
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Abstract
The pediatric craniofacial trauma literature largely focuses on the management of mandible fractures, with very little information focusing on pediatric midface fractures, specifically nasoorbitethmoid (NOE) fractures. Because the diagnosis and surgical treatment plan for adult NOE fractures is well established in the literature, the treatment algorithms for NOE are essentially a transfer of adult practices to pediatric patients. This article reviews the differences between the pediatric and adult facial skeleton and the pathology and presentation of NOE fractures in the pediatric craniomaxillofacial skeleton. It also presents the effects of NOE fractures on the growth and development of the pediatric facial skeleton and describes the current surgical management for NOE fractures.
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Schaller B, Hosokawa S, Büttner M, Iizuka T, Thorén H. Occurrence, types and severity of associated injuries of paediatric patients with fractures of the frontal skull base. J Craniomaxillofac Surg 2011; 40:e218-21. [PMID: 22078497 DOI: 10.1016/j.jcms.2011.10.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/27/2011] [Accepted: 10/06/2011] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To clarify the occurrence, sites, and types of associated injuries in paediatric patients with fractures of the anterior skull base. STUDY DESIGN Retrospective analysis of files of 49 patients aged up to 18 years. RESULTS Associated injuries were observed in 91.8% of the patients. Observed most frequently were fractures of the skull vault (85.7%), brain injury (59.2%), facial fracture (42.9%), lung contusion (18.4%) and fractures of the upper extremities (14.3%). Multiple injuries were observed in 55.1% and polytrauma in 42.9%. The mortality rate was 10.2%. CONCLUSIONS Paediatric patients with fractures of the anterior skull base frequently present with associated injuries, with many having, multiple associated injuries including polytrauma. These patients should be treated in multidisciplinary trauma units.
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Affiliation(s)
- Benoit Schaller
- Department of Cranio-Maxillofacial Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
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Fattahi T, Dipasquale J. Utility of the pericranial flap in frontal sinus and anterior cranial fossa trauma. Int J Oral Maxillofac Surg 2010; 38:1263-7. [PMID: 19836208 DOI: 10.1016/j.ijom.2009.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 07/15/2009] [Accepted: 09/21/2009] [Indexed: 10/20/2022]
Abstract
Complex injuries to the frontal bar of the upper face can cause significant damage to the anterior cranial fossa. One of the biggest challenges in the repair of such injuries is the prevention of a cerebrospinal fluid leak and separation of the brain from the nasal cavity. Although many autogenous and alloplastic materials can be used for this purpose, the pericranial flap offers a viable alternative. This axially based flap is readily available, does not require an extra harvest site, and can be fashioned appropriately to obliterate the frontal sinus and/or line the anterior cranial base to decrease the possibility of cerebrospinal fluid leaks. The authors' experience with this flap in complex frontal sinus and anterior cranial fossa injuries is described.
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Affiliation(s)
- T Fattahi
- Division of Oral & Maxillofacial Surgery, University of Florida Health Science Center, 653-1 W. 8th Street, Jacksonville, FL 32209, United States.
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Zubillaga-Rodríguez I, Falguera-Uceda M, Sánchez-Aniceto G, Montalvo-Moreno J, Díez-Lobato R. Abordaje subcraneal. Consideraciones técnicas y aplicaciones en patología traumática craneofacial. Neurocirugia (Astur) 2010. [DOI: 10.1016/s1130-1473(10)70099-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The orbit is located in the middle third of the face, composed of several bones and surrounded by complex anatomic structures so that orbital fractures (OF) often involve other parts of the face. A staging system for classifying OF is of paramount importance in order to exchange information between trauma centers. Several classifications have been proposed for describing OF but they have not a single method applicable to the whole orbit. Here, a classification for OF that can be summarized with four abbreviations is proposed. Four letters define the localization (F = frontal, N = nasal, M = maxillary and Z = zygomatic bone fracture), two acronyms describe fragment shift (in = blow-in or out = blow-out), four numbers define ocular movement impairment (1 = superior, 2 = internal, 3 = inferior, and 4 = external extrinsic muscular deficit) and two acronyms describe eye position (EX = exophthalmos and ENO = enophthalmos). To evaluate the suitability of the proposed classification a retrospective study on a series of 190 OFs is performed. Age, gender, new stage, clinical diagnosis at admission, type of surgery, and need for graft for orbital reconstruction are considered. A good correlation between the proposed classification and the studied variables is detected. In conclusion, the proposed classification is a simply and precise method to stage OF. It can summarize OF and be used in the daily practice. However, it is our belief that a multi-center study should be performed before the effectiveness of the proposed classification can be clearly stated.
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Affiliation(s)
- Francesco Carinci
- Department of Maxillofacial Surgery, University of Ferrara, Ferrara, Italy.
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Madhusudan G, Sharma RK, Khandelwal N, Tewari MK. Nomenclature of Frontobasal Trauma: A New Clinicoradiographic Classification. Plast Reconstr Surg 2006; 117:2382-8. [PMID: 16772946 DOI: 10.1097/01.prs.0000218794.28670.07] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-velocity accidents cause significant injury to the cranial and facial skeleton. Frontobasal fractures include fractures of the upper third of the face and anterior skull base. The pattern and classifications of these fractures are poorly understood at present. The authors have attempted a new comprehensive classification based on detailed clinicoradiographic evaluation. METHODS A prospective study was undertaken in a tertiary care hospital in 1 calendar year (July of 2000 to June of 2001). All 63 patients with frontobasal fractures had detailed clinical and radiographic evaluation with plain radiographs and high-resolution computed tomographic scan. The fractures were classified as frontal, basal, and combined. Areas were separated as central (designated type 1) and lateral (designated type 2) to differentiate the pattern in the sagittal plane according to the site of impact. Combined fractures involving both central and lateral areas were designated type 3. These could be further classified into unilateral or bilateral or pure or impure, depending on the absence or presence of midfacial fractures. RESULTS The fractures were subdivided into nine types considering the whole lateral and anteroposterior extents of the frontobasal region. The most common was the combined frontobasal type (30.16 percent). We found the pure type in 38.1 percent (24 of 63) and the impure type in 61.9 percent (39 of 63) of patients. Cerebrospinal fluid leaks occurred more commonly in impure types of frontobasal fracture. Blunt trauma leading to closed frontobasal fracture was seen in 35 patients. Penetrating trauma with open fractures was found in 28 patients and cerebrospinal fluid leak through the wound was seen in six of them. CONCLUSIONS The new comprehensive classification clearly defines the anatomical areas within the frontobasal region, the nature of injury, and its association with midfacial injuries, and is helpful in planning the approach to their exposure in surgery.
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Affiliation(s)
- G Madhusudan
- Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Abstract
OBJECT Forehead, anterior cranial base and orbito-naso-ethmoidal fractures, combined with brain injuries and dural tears, constitute a frequent pattern of injury in infants and children less than 5 years of age when major anterior craniofacial trauma occurs. Fractures of the orbital roof, despite the common blow-out floor fractures, are considered uncommon events. In children younger than 7 years this pattern of fracture may be a consequence of nonpneumatized frontal sinuses. METHODS Complete assessment using CT scans combined with neurosurgical, ophthalmological, anesthesiological and craniofacial reconstructive evaluations are necessary to repair the injured dura and craniofacial skeleton. The coronal approach provides the best exposure of the fractured regions to the surrounding regular structures. CT scans are useful in defining the extent and the pattern of the fractures. Once the brain and dura injuries have been managed by the neurosurgeon, the anterior cranial base must be reconstructed by applying the basic craniofacial principles, reduction and stabilization of fractures, sealing off the anterior cranial base. We present four cases of frontobasilar fractures in children, two of which involved the orbital roof. CONCLUSIONS The treatment of pediatric maxillofacial traumas, therefore, requires consideration of different factors from those in adults, and a different therapeutic approach: respect of the functional matrix (growth principle) and employment of the least invasive surgical approach. Fixation that adequately stabilizes the facial skeleton is also required. The need to provide rigid bony fixation in the surgical treatment of craniofacial disorders in children without impacting the growth has inspired the evolution of operative techniques and fixation devices, with the development of reabsorbable bone fixation. When bony defects are present or reconstruction of the complete orbital roof and anterior cranial base is required, autogenous cranial bone is used.
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Affiliation(s)
- Luigi Clauser
- Unit of Cranio-Maxillofacial Surgery, Center for Orbital Pathology, St. Anna Hospital and University, Corso Giovecca 203, 44100, Ferrara, Italy.
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Matteini C, Renzi G, Becelli R, Belli E, Iannetti G. Surgical Timing in Orbital Fracture Treatment: Experience with 108 Consecutive Cases. J Craniofac Surg 2004; 15:145-50. [PMID: 14704581 DOI: 10.1097/00001665-200401000-00035] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Orbital fractures can lead to esthetic deformities and functional impairments, and adequate surgical timing is considered important in obtaining good results from surgery. By means of chart review, a retrospective analysis was carried out in 108 consecutive cases of pure orbital fractures to investigate the differences in surgical timing and the correlations with patient age and clinical and radiographic findings. In this analysis, surgical timing of pure orbital fractures was strongly related to the combination of parameters such as anatomical location of the fracture, eventual exposure of the fracture, cerebrospinal fluid (CSF) leakage or penetrating wounds, age of patients, eventual functional impairments or muscle entrapment, and serious conditions of compression or ischemia. As the data confirmed, an urgent approach was considered indispensable in severe orbital apex fractures and in orbital fractures with CSF leakage, penetrating objects, or exposure. Early surgery was necessary within 3 days in children with diplopia (type IIIb) and mainly within 7 days in adults with double vision (type IIIa). Delayed surgery, within 12 days in all cases, was performed orbital wall fractures with no impairments (type II) or in orbital rim fractures (type I). Data from this retrospective analysis confirm the need for an aggressive approach to all orbital fractures. In our experience, surgery was performed within 12 days and most orbital fractures were treated during the first week after trauma, which is earlier than previously reported.
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Hochuli-Vieira E, Real Gabrielli MF, Garcia IR, Cabrini Gabrielli MA. Frontal sinus obliteration with heterogeneous corticocancellous bone versus spontaneous osteoneogenesis in monkeys (Cebus apella): histologic analysis. J Oral Maxillofac Surg 2003; 61:214-21. [PMID: 12619000 DOI: 10.1053/joms.2003.50040] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE In this study, we evaluated the results of spontaneous osteoneogenesis of the frontal sinus with autogenous bone plug versus obliteration with heterogeneous (human) bone in monkeys (Cebus apella). MATERIALS AND METHODS Eight young adult male C apella monkeys underwent an ostectomy of the anterior wall of the frontal sinus, removal of the sinus mucosa, and inner decortication of the bony walls and then were divided into 2 groups of 4 each, as follows. Group I monkeys underwent obliteration of the nasofrontal ducts with a free segment of frontallis muscle and corticocancellous heterogeneous bone, followed by full obliteration of the sinus with corticocancellous heterogeneous bone (Dayton Regional Tissue Bank, Dayton, OH). Group II monkeys underwent obliteration of the nasofrontal ducts with a frontal muscle segment and tibial autogenous bone plug, without full obliteration of the frontal sinus. In all animals, the sinus anterior wall was repositioned and fixed with 1.0 plate and screws. The monkeys were killed after 180 days, and routine laboratory procedures were followed for hematoxylin-eosin staining and histologic evaluation of the specimens. RESULTS The 2 studied techniques were both effective in obliterating the frontal sinus with newly formed bone. The nasofrontal ducts were obliterated by new bone formation or fibrous tissue (1 animal only). CONCLUSIONS Both methods used for frontal sinus obliteration were effective; the heterogeneous bone (human bone) was well tolerated and presented low antigenicity. The nasofrontal duct obliteration with autogenous muscle associated with autogenous tibial bone (group II) or with heterogeneous bone (group I) was effective, isolating the frontal sinus from the nasal cavity. The spontaneous obliteration resulted, in the period analyzed, in earlier bone maturation compared with the obliteration by heterogeneous bone.
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Affiliation(s)
- Eduardo Hochuli-Vieira
- Department of Oral and Maxillofacial Surgery, Dental School at Araraquara, Unesp, Sao Paulo, Brazil.
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Buitrago-Téllez CH, Schilli W, Bohnert M, Alt K, Kimmig M. A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography. Injury 2002; 33:651-68. [PMID: 12213415 DOI: 10.1016/s0020-1383(02)00119-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A comprehensive classification of midfacial/craniofacial fractures, based on two- and three-dimensional computed tomography (2D and 3D-CT) is presented. We performed a postmortem analysis of 24 patients who had died from trauma with signs of craniofacial fractures, based on 2D and 3D-CT studies with pathoanatomical findings. In addition, CT findings for 100 patients with craniofacial injuries requiring an emergency CT were correlated with surgical findings and follow-up results. On the basis of the analysis of a total of 377 fractures a classification system is proposed. The system is based on the use of the AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) scheme, defining three types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest). The craniofacial region is divided into three units: the lower midface (I), the upper midface (II) and the craniobasal-facial unit (III). Lateral and central fractures are also distinguished. Type A fractures are non-displaced fractures, type B are displaced fractures and type C are complex/defect fractures. Groups A1, B1 and C1 comprise fractures of an isolated unit; groups A2, B2 and C2, combined fractures without involvement of the skull base; and groups A3, B3 and C3 are those combined fractures with involvement of the skull base. A correlation between the severity of the fracture and (i). the number of posttraumatic functional limitations (Spearman rank test, correlation coefficient r=0.42), (ii). the need for bone grafting or dural plastic (r=0.39) and (iii). facial asymmetry (r=0.37), was observed. The proposed classification system allows standardised documentation of midfacial and craniofacial fractures, including those not precisely defined by the Le Fort classification scheme.
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Affiliation(s)
- Carlos H Buitrago-Téllez
- Department of Radiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
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Amrith S, Saw SM, Lim TC, Lee TK. Ophthalmic involvement in cranio-facial trauma. J Craniomaxillofac Surg 2000; 28:140-7. [PMID: 10964549 DOI: 10.1054/jcms.2000.0138] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This is a retrospective descriptive case study which will look into the spectrum of ophthalmic involvement in cases with orbital and eye injuries after cranio-facial trauma and to analyse the visual and motility outcome. MATERIAL One hundred and four cases with ophthalmic involvement after cranio-facial trauma that were referred to and seen in the eye department of a tertiary teaching hospital in Singapore between 1991-97 were included in the study. METHODS The case records of 104 such patients were traced. The demographic data, the mode of injury, the type of fracture sustained and presence of serious eye injury were noted. The details about visual acuity, significant diplopia and enophthalmos at the first and last visits were charted. Presence of traumatic optic neuropathy including the type of treatment given was recorded. RESULTS There was a male preponderance (82%). The industrial accidents were 21%, only next to road traffic accidents, which constituted approximately 36.5%. The predominant types of fractures seen were blow-out orbital fractures, complex fractures comprising of Le-Fort II, III, panfacial and fronto-basilar skull fractures. Diplopia was the most common presenting feature (40%) with visual acuity disturbance (23% having <6/60) as the next most common finding. Traumatic optic neuropathy was seen in 20% of patients and serious eye injury was present in 9% of patients. The incidence of traumatic optic neuropathy was significantly higher (p<0.001) in patients with complex fractures and fronto-basilar fractures, as compared to the blow-out and zygomatico-maxillary fractures. Analysis of final results indicated 15% as having significant diplopia in one or more gazes and 12.5% as having a vision of <6/60. CONCLUSION Diplopia and visual acuity disturbances seem to be the most common ophthalmic presentations in cranio-facial trauma. A significant number of patients suffer from poor vision and significant diplopia despite treatment.
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Affiliation(s)
- S Amrith
- Singapore National Eye Centre, Singapore.
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