Management of midface maxillofacial trauma

The management of midface trauma continues to challenge maxillofacial surgeons. The complex local anatomy and functional and cosmetic importance of the region make precise surgical correction and reconstruction essential to success.

Dural suturing for repair of cerebrospinal fluid leak in transnasal transsphenoidal surgery

OBJECTIVE

Repair of a cerebrospinal fluid (CSF) leak after transsphenoidal surgery (TSS) is usually accomplished using various graft materials. These methods are effective in most, but not all, cases.

METHODS

Since 2006, we have been directly suturing the sellar floor dura in patients with an intraoperative CSF leak. Fat and/or fascial grafts were utilized only when a major CSF leak developed. The incidence of postoperative CSF rhinorrhea was compared before and after the suture.

RESULTS

Postoperative CSF rhinorrhea developed in 3.7% (7 out of 188) of cases before 2005, but never since the dural suture was introduced (0 out of 136, 0%; P = 0.0229). Although watertight closure was not achieved in some cases, narrowing the dural defect and supporting the intrasellar graft was attained in every case. Surgical time was approximately 30 min longer in patients who underwent dural suture (148 +/- 42 min) than those who did not (119 +/- 37 min; P = 0.0001).

CONCLUSION

Direct suturing of the sellar dura is a simple, safe, and reliable surgical technique for repairing CSF leaks after TSS. Using this procedure, more than 70% of patients with an intraoperative CSF leak can avoid autologous tissue grafts.

[Anatomic approach to the sphenooccipital synchondrosis in newborns and infants with craniocerebral injury]

An anatomic approach is developed to sphenooccipital synchondrosis in newborn infants and nurslings. After removal of the squamous portion of the occipital bone by the method of Medvedev, opening of the cerebrospinal canal, removal of the spinal cord and hypophysis, two parallel cuts converging at an angle of approximately 90 degrees were made with a dissecting blade saw along both sides of sella turcica towards the anterior edge of the great occipital foramen to transect the sphenoid bone and main part of the occipital bone. The resulting osteochondrous fragment showed up defects in synchondrosis including consolidated ones.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

[Neurobehavioral disability following traumatic brain injury: 7 cases that exhibited neuropsychological impairments and neuropsychiatric syndromes]

The term "higher brain dysfunction" is used to describe neurobehavioral disability or neuropsychological impairment in Japan. Patients with sphenoidal injury and diffuse axonal injury after traumatic brain injury manifest clinical and neuropsychological symptoms. Following closed head injury, patients exhibit a variety of symptoms. In this paper, the author describes neuropsychological dysfunctions/courses and neuropsychiatric syndromes in 7 representative cases who were characterized by : (1) attention deficit, (2) memory dysfunction, (3-a) perseveration, (3-b) dysexecutive syndrome, (4) disorders of drive and motivation, (5) emotional deficits, and (6) lack of ability to recognize the effects of his/her behavior. There are wide varieties of difficulties in assessment, treatment, and rehabilitation for cognitive impairment and behavioral disability after traumatic brain injury. Neuropsychiatrists are expected to participate in this field in Japan.

[Cranial wounds of the skull caused by a fencing-foil]

Penetrating stab cranial wounds of the skull by fencing-foil are rare in western countries.

CASE REPORT

This 46-year-old man suffered a penetrating stab wound of the skull through the right orbital region. As a consequence he developed an intracranial hematoma requiring surgical evacuation.

DISCUSSION AND CONCLUSIONS

Damage of intracranial contents due to transorbital penetrating objects other than missiles is a rare event.

BioGlue for prevention of postoperative cerebrospinal fluid leaks in transsphenoidal surgery: A case series

BACKGROUND

The efficacy of BioGlue (CryoLife, Inc, Atlanta, Ga) surgical adhesive in transsphenoidal surgery was assessed as an adjunct in the prevention of postoperative CSF leaks.

METHODS

All patients in whom BioGlue was used for an intraoperative skull base reconstruction were retrospectively identified. Intraoperative CSF leaks were graded according to size (grade 1, small weeping leak without obvious diaphragmatic defect; grade 2, moderate leak with a definite diaphragmatic defect; grade 3, large diaphragmatic and/or dural defect). CSF leak repair was tailored to CSF leak grade. BioGlue was applied as a reinforcement over collagen sponge as the last layer of the repair.

RESULTS

Over 28 months, a total of 282 patients underwent endonasal surgery. Of these patients, 124 (79 women; age range, 8-84 years), in 128 procedures, had an intraoperative CSF leak repair reinforced with BioGlue. Pathology included 80 pituitary adenomas, 11 craniopharyngiomas, 7 Rathke's cleft cysts, 6 chordomas, 5 meningiomas, 4 spontaneous CSF leaks, 3 arachnoid cysts, and 8 other parasellar pathologies. There were 62 (48.4%) grade 1, 41 (32.0%) grade 2, and 25 (19.5%) grade 3 leak repairs. The overall repair failure rate was 1.6% (2 cases), with the failures occurring in patients with grade 3 leaks, including 1 who developed meningitis; there was no failure of grades 1 and 2 leaks. The 2 failures were attributed largely to technical aspects of the repair rather than to failure of BioGlue per se.

CONCLUSIONS

BioGlue appears to be an effective adjunct in preventing postoperative CSF leaks after transsphenoidal surgery. However, careful attention to technical details of the repair is still required to prevent failures, especially when closing large dural and diaphragmatic defects.

Computer-Assisted Extracorporeal Orbital Reconstruction After Optic Nerve Decompression by Removal of Sphenoid Bone

The removal of sphenoid bone parts was performed by the admitting neurosurgeons on a patient who presented an optic nerve compression syndrome. Beside the orbital trauma, an extensive midfacial trauma was sustained with dislocated multifractures of the zygomatic complex. In a secondary procedure, the orbital cavity was reconstructed successfully using 3 different methods of computer-assisted surgery. First, the reconstruction of the zygomatic complex was controlled intraoperatively by a virtual model obtained by mirroring the unaffected side to the affected side. Second, extracorporeal bone parts were virtually preoperatively relocated and orientated. The reconstruction of the orbital cavity by the insertion of these bony fragments was performed intraoperatively as planned after the zygomatic complex reconstruction. Third, the virtual reconstruction of the orbital floor was performed using preoperatively individually bent and preformed orbital titanium mesh. Combinations of these methods demonstrate the practical and high value of computer-assisted surgery in complex reconstructive craniofacial surgery.

Blindness after Le Fort I osteotomy: a possible complication associated with pterygomaxillary separation

INTRODUCTION

Visual loss after Le Fort I osteotomy is a devastating complication the mechanism of which is not always clear.

METHODS

A case report of blindness following Le Fort I osteotomy is presented. The literature on the various skull base complications associated with Le Fort I osteotomies is reviewed and the mechanisms of these complications discussed.

CONCLUSION

The radiological findings in this case are similar to those previously reported. They strongly support the hypothesis that an adverse transmission of forces associated with pterygomaxillary separation via the sphenoid bone to the intra- and extracranial portions of the skull base is the main reason for injury to the optic and other cranial nerves as well as to the branches of the carotid artery.

Anterior skull base fractures

Anterior skull base trauma evaluation and management has historically been difficult to systematically study secondary to the relative rarity of its occurrence, associated major morbidity and high mortality, and poor radiographic techniques. It has only been recently that improved care has allowed for decreased morbidity and mortality. The advent of computed tomography imaging techniques has led to anatomic characterization and detailed study of injury patterns. This article reviews current techniques for evaluation and management of the associated sinonasal, orbital, and neurologic sequelae of anterior skull base injuries.

Indriven sphenoid wing as a cause of post-traumatic epilepsy

Post-traumatic epilepsy is more frequent after severe head injuries, however the severity of the trauma is not always correlated with the injured brain tissue. We report a patient whose seizures developed 4 years after a face trauma. Upward displacement of the sphenoid wing caused a contusion at the orbital surface of the frontal lobe. Computed tomography, magnetic resonance imaging and electroencephalographic findings are presented. The patient responded well to commonly used antiepileptic drugs.

Clinical signs of orbital wall fractures as a function of anatomic location

OBJECTIVE

The objective of this study was to see whether clinical signs of medial orbital wall fractures distinguished these fractures from fractures of the lateral orbital wall and the orbital floor.

STUDY DESIGN

The orbital fractures of 424 patients were analyzed. The patients were divided into 2 groups: (1) patients with orbital fractures with a medial orbital wall component and (2) patients with orbital fractures without a medial orbital wall component.

RESULTS

Orbital fractures with involvement of the medial orbital wall showed a significantly higher incidence (P =.001) of diplopia and exophthalmos (P =.039) than fractures without involvement of the medial wall.

CONCLUSION

Posttraumatic orbital clinical signs are associated with a higher incidence of medial orbital wall component fracture. Apparent lack of involvement of the medial orbital wall should not be an exclusion criterion for a surgical intervention when clinical orbital signs exist.

Skull-base trauma: neurosurgical perspective

Trauma to the cranial base can complicate craniofacial injuries and lead to significant neurological morbidity, related to brain and/or cranial nerve injury. The optimal management involves a multidisciplinary effort. This article provides the neurosurgeon's perspective in management of such trauma using a 5-year retrospective analysis of patients sustaining skull-base trauma. The salient features of anterior and middle skull-base (temporal bone) trauma are summarized, and the importance of frontal basilar trauma as well as brain injury is evident. With these injuries, all cranial nerves (except 9 to 12) are at risk; the olfactory nerve and the facial nerve are the first and second, respectively, to sustain injuries. This retrospective analysis provides a better understanding of cranial base trauma and its management. It emphasizes the multifaceted nature of such trauma and the need to recognize anterior skull-base complications, including cerebrospinal fluid leak and brain injury.

Management of traumatic optic neuropathy

Visual loss caused by trauma to the optic nerve is a well-recognized sequela to cranio-maxillofacial trauma. The authors reviewed their experience with 90 patients with pure traumatic optic neuropathy and optic nerve trauma with concomitant maxillofacial injuries. All patients were treated with intravenous steroids. Those not improving underwent extracranial optic canal decompression. Patients with initial visual acuity of 20/100 or better all responded favorably with improvement in visual acuity or visual field to a course of intravenous megadose corticosteroids. Patients with initial vision of 20/200 or worse who failed to respond to corticosteroids may have improved visual function after undergoing extracranial optic canal decompression. Preoperative and postoperative computed tomography scans on 6 patients enhanced with intrathecal iopamidol indicate the site of optic nerve compression to be at the optic canal. This article discusses the diagnosis and the medical and surgical treatment of pure and complex optic nerve injuries.

Longitudinal brainstem laceration associated with complex basilar skull fractures due to a fall: an autopsy case

This report describes an autopsy case of a rare longitudinal brainstem laceration associated with complex basilar skull fractures. The victim was a 40-year-old male who died immediately after falling from a roof (9.2m in height) of a factory onto a concrete floor. The postmortem examination revealed an incomplete ring fracture of the base of the skull with longitudinal fractures of the sphenoid (clivus of the dorsum sellae turcicae) and occipital bones, cerebral contusions in the frontal and temporal poles, a longitudinal brainstem laceration at the posterior median sulcus of the pons accompanied with multiple contusional hemorrhages in the brainstem and corpus callosum. Related blunt-force injuries were observed in the parieto-occipital region of the head, shoulder and upper back involving the fractures of the cervical and thoracic vertebrae, and sternum and ribs, indicating a huge impact to the occiput and subsequent impression of the vertebral column into the base of the skull due to violent anteroflexion of the neck, which caused the complex basilar skull fractures, contusions and longitudinal laceration of the brainstem.

Le Fort I osteotomy with sparing fracture of lateral pterygoid plate

This study aimed to clarify the relation between the anatomical variations of the pterygomaxillary region and fracture of the pterygoid plate during Le Fort I osteotomy. We present a secure method to separate maxillary tuberosities from pterygoid plates without injuring the pterygoid plates. Thirty specimens of hemisection of Korean skulls were used for the study. The maxilla was sectioned transversely on the floor of the pyriform aperture and posteriorly to the lateral pterygoid plate with a mechanical saw. The section was 5 to 6 mm above the tooth roots. The pterygomaxillary junction was separated with a curved osteotome in two steps: initially with light tapping of the shallow groove 2 to 3 mm anterior to the pterygomaxillary fissure at a half right angle and then changing the course of forceful tapping to more than 60 degrees. The maxillary tuberosity separated from the medial and lateral pterygoid plates during the procedure was grouped into the "disjunction group" (24 of 30, 80%) and the pterygoid plates fractured were grouped into the "fracture group" (6 of 30, 20%). The thickness of the pterygomaxillary region (T) was significantly greater in the disjunction group than in the fracture group (P = 0.034). The concavity of the pterygomaxillary fissure (C) was significantly deeper in the disjunction group than in the fracture group (P = 0.020). There was no significant difference of width of the pterygomaxillary fissure between the disjunction group and the fracture group (P = 0.169). The thin pterygomaxillary region and less concave pterygomaxillary fissure on the preoperative computed tomography scan draw precautionary attention to vulnerable pterygoid plates fractured in the procedure of Le Fort I osteotomy.

Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients

OBJECT

The author's personal series included 148 patients who sustained traumatic frontobasal injuries and were treated between 1986 and 1999. Included in this study are 74 of 148 patients with acute injuries and complex frontobasal lesions involving the frontal sinus, the cribriform/ethmoid roof complex, one or both orbital roofs, and the planum sphenoidale.

METHODS

Surgery was delayed for up to 4 weeks postinjury in most patients (67 cases), whereas 17 with space-occupying hematomas and perforating injuries required early surgery. In 30 patients additional surgery was required to treat maxillofacial fractures, which was performed as a one-stage procedure together with the neurosurgical operation. The author performed a standard bifrontal craniotomy in which an intradural or combined intradural-extradural approach was used in all cases. Four patients developed ascending meningitis in the preoperative period. As a result of surgical treatment one patient died, another two patients suffered from permanent defects, and three suffered from transitory neurological worsening. In two patients recurrence of a cerebrospinal fluid fistula occurred within a 3-month period posttreatment but was successfully obliterated during reoperation. In the author's experience the intradural approach is comparable in terms of the morbidity, mortality, and success rates with extracranial approaches; additionally the intradural approach provides full visualization of the intracranial lesion. Useful olfactory nerve function can only be preserved if both olfactory nerves are left intact and not crushed during initial injury; this occurred in only five patients in this series.

CONCLUSIONS

If possible, surgical treatment of more complex lesions should be delayed until the 2nd or 3rd week following traumatic injury. With antibiotic prophylaxis the risk that ascending meningitis will occur prior to surgery is low. If the patient is systemically stable and brain swelling has resolved, even extensive one-stage neurosurgical/maxillofacial procedures are well tolerated.

Secondary fractures of Le Fort I osteotomy

PURPOSE

To report the ophthalmic complications of Le Fort I osteotomy for the correction of dentofacial deformities and to determine the maximal compressive loads applied during pterygomaxillary separation in a cadaver model.

METHODS

Two cases of ophthalmic complications arising after Le Fort I osteotomy are reported. Le Fort I osteotomy was performed on five cadavers. The maximal compressive load applied during pterygomaxillary separation was recorded with a 10 kN (3,000 lbf) load cell of a MTS Mini-Bionix servo-hydraulic machine (MTS, Eden Prairie, MN, U.S.A.). A paired t test was used to compare forces applied to the right and left sides. Computed tomography scans of each specimen were obtained after Le Fort I osteotomy to document secondary fractures. The skulls were subsequently stained with 1% fuschin red to highlight secondary fractures.

RESULTS

Maximum compressive loads during pterygomaxillary separation ranged from 22 N (5.0 lbf) to 162 N (36.5 lbf), with an average of 106 N (23.8 lbf) (SD 47.6 N [10.7 lbf]). Forces applied on the first operative side were significantly greater than forces applied on the second operative side (p = 0.0034). Secondary fractures were found in three specimens by computed tomography and in two specimens by 1% fuschin red. All secondary fractures occurred on the second operative side.

CONCLUSION

Secondary fractures in the Le Fort I osteotomy procedures occurred on the side opposite the greater maximal compressive load and on the second operative side.

Tension forces in relation to LeFort III osteotomies

Complications associated with LeFort III osteotomies have led to modifications of the procedure. Attempts to decrease morbidity include performing incomplete osteotomies or eliminating pterygomaxillary dysjunction. The purpose of this study was to determine the amount of tension required for separation of the midface from the pterygoid plates and to observe the fracture patterns. An Instron machine (Instron Corporation, Canton, MA) was used to measure the tension forces in 16 cadaver skulls divided into five groups. The groups varied as to whether the osteotomies were complete and whether pterygomaxillary separation was performed. Specimens with incomplete osteotomies and without pterygomaxillary separation required greater tension forces for separation and exhibited a high percentage (47%) of unfavorable fractures. Because high amounts of tension are required leading to unpredictable separations, we recommend complete osteotomies with pterygomaxillary dysjunction when performing LeFort III osteotomies.

The use of nasal endoscopy to control profuse epistaxis from a fracture of the basi-sphenoid in a seven-year-old child

A seven-year-old child sustained a fracture of her basisphenoid resulting in profuse, life-threatening haemorrhage which could not be controlled with a post-nasal pack. The fracture site was identified using rigid endoscopy and packed with oxidized cellulose, resulting in immediate control of the haemorrhage. The use of the nasal endoscope in the management of posterior epistaxis is discussed.

Unusual penetrating faciocranial injury caused by a knife: a case report

Penetrating head and neck trauma in children is uncommon and are potentially life-threatening injuries. Penetrating trauma to the head in children is a challenging problem for both the initial evaluating physicians and surgeons. We report upon a patient who had fallen from a tree while cutting vegetables and sustained a penetrating faciocranial injury caused by his knife. Clinical examination showed a knife which had entered his face in the right preauricular, pre-temporomandibular joint area below the zygomatic arch. His left bulbus oculi was exophthalmic and a complete ptosis was present. He was fully conscious. The only abnormal finding was complete left visual loss. The other neurological ophthalmological and systemic physical evaluations were normal. The Glasgow Coma scale score was 14. The modalities of treatment and the outcome of the operation are described and the management of similar injuries is discussed.

The significance of carotid canal involvement in basilar cranial fracture

OBJECTIVE

Basilar cranial fractures have been associated with injury to the carotid artery. We sought to determine whether fracture through the carotid canal was a significant risk factor for carotid injury.

METHODS

A retrospective chart review was performed, and 230 patients with basilar cranial fractures were identified. Fifty-five of the 230 patients had visible fractures that extended through one or both carotid canals (CC fx group). Evidence for vascular injury, based on medical records, angiography, magnetic resonance imaging, and other studies, was compiled. The anatomic characteristics of the fractures were also noted and recorded.

RESULTS

Ten patients in the CC fx group suffered vascular complications; for six of them, the complications were directly related to the intracranial carotid artery. This compares to four patients in the non-CC fx group with vascular complications (P < 0.005), only one of which was carotid-specific (P < 0.005). The most common site of fracture through the canal was at the junction of the lacerum and cavernous portions of the canal (the spheno-occipital suture) (62% of all carotid canal fractures occurred at that site); however, vascular injury was seen most often in patients who sustained fractures through the petrous segment (67% of carotid canal-specific injuries occurred in that group, and 25% of patients with petrous canal fractures suffered carotid injury, [P = not significant]). The mean Glasgow Coma Scale score and the mean age were both lower (P < 0.05) in the CC fx group.

CONCLUSION

Vascular complications are more frequently observed after basilar cranial fractures when there is involvement of the carotid canal. The lacerum-cavernous junction, which is partly formed by the spheno-occipital suture, is the most frequently fractured segment of the carotid canal. Fracture through the petrous segment of the carotid canal is associated with a relatively high incidence of carotid injury. Fracture through the carotid canal may serve as an index of injury severity, because patients with these fractures suffered more severe head injuries.

Nasopharyngeal cavity narrowing associated with posterior maxilla and pterygoid plate fracture: report of three cases

The CT appearances of three cases with severe nasopharyngeal cavity narrowing are described. In all cases the facial trauma was due to a motor vehicle accident. These cases demonstrate that posterior maxilla and pterygoid plate fractures can cause significant nasopharyngeal soft tissues swelling, most likely due to haemorrhage and/or oedema. Severe nasopharyngeal cavity narrowing could cause difficulty in elective nasogastric tube and endotracheal tube intubation via the nasopharyngeal route.

Bursitis of the hamular process. Part II: Diagnosis, treatment and report of three case studies

In the first part of this series of two papers, the bursa of the tendon of the tensor veli palatini muscle was demonstrated and described histologically. In Part II, the symptoms and the process of diagnosis of bursitis of the hamular process is presented. Additionally, recommended treatment options will be discussed. The article presents three case reports.

Superolateral dislocation of an intact mandibular condyle into the temporal fossa: a case report

An unusual case of superolateral dislocation of an intact mandibular condyle into the temporal fossa is reported. The different methods of treatment and the difficulties that may arise in the treatment of such cases are discussed briefly, and the literature is reviewed.

Endoscopic repair of traumatic CSF rhinorrhea in a pediatric patient

Cerebrospinal fluid (CSF) rhinorrhea typically results from trauma to the skull base, producing leaks through either the cribiform plate region or the sphenoid bone. Traditional approaches to the repair of such leaks include a frontal craniotomy or external ethmoidectomy. An endoscopic approach through the nose has also proven to be successful. A 7-year-old male suffered traumatic CSF rhinorrhea and development of a meningocele in the region of the cribiform plate. After demonstrating the site of the leak with fluorescein dye, the defect was repaired via a transnasal endoscopic approach. The evaluation of the child with CSF rhinorrhea, including the presenting symptoms and signs and the radiographic assessment, is presented. The variety of approaches, types of repair and post-operative care are also discussed.

Traumatic chiasmal syndrome: a feature photograph

Traumatic chiasmal neuropathy results from injury to the face, sphenoid and clivus. Its pathogenesis remains enigmatic. Because of its close relationship to the pituitary gland, hypothalamus and internal carotid artery, a neuro-ophthalmic evaluation and imaging is needed in such cases. We present a patient who developed traumatic chiasmal syndrome after an automobile accident. Computed tomographic scan showed fracture of the sella turcica. A carotid angiography showed a traumatic pseudoaneurysm of the internal carotid at the base of the skull.

Fractures of the floor of the anterior cranial fossa

We treated 28 patients with anterior cranial fossa floor fractures. Computed tomography (CT) scans adjusted to bone density disclosed three fracture types: (1) penetrating fractures through the orbita or ethmoid sinus; (2) simple or multiple linear fractures; and (3) extensive comminuted anterior cranial fossa floor fractures. Thirteen patients underwent emergent surgery for treatment of open depressed fractures (most common in type 3 fractures), for foreign bodies (in type 1 fractures), and for optic canal decompression. Large dural lacerations were always present in patients with type 3 fractures, and repairs were made with dural substitutes. Only one patient developed postoperative cerebrospinal fluid leakage. Nine (32%) of the patients in our series had visual involvement, but visual acuity recovered or improved in six patients. Our study shows that initial neuroradiologic evaluation with CT scans is important in patients with frontobasal fractures, and that secure dural repair during primary operation helps prevent cerebrospinal fluid leakage.

[A study of the intraorbital blood flow using ultrasound color Doppler mapping images in optic canal fracture cases]

Ultrasound color Doppler flow mapping image (CFMI) equipment, SSA-270A (Toshiba Co) was used to measure the blood flow velocity of the ophthalmic artery (OA) and the central retinal artery (CA) in eyes with optic canal fracture. The maximal blood flow velocity (V max), the minimal blood flow velocity (V min), the mean blood flow velocity (V mean), and the resistance index (RI) before and after transethmoidal decompression of the optic nerve were compared. The examination was conducted on 13 patients. There was no difference in blood flow velocity in the CA after the operation. Pre-operative V max and RI of the OA in the damaged eyes were lower than in normal eyes, but they increased the day after the operation. We measured the intraorbital blood flow velocity by CFMI because ultrasound does not penetrate bone. Since the peripheral artery from the optic foramen did not change after the operation, we concluded that the peripheral blood flow of OA had been quantitatively improved by the trans-ethmoidal decompression of the optic nerve.

Patterns of skull base fracture: a three-dimensional computed tomographic study

Three-dimensional (3D) computed tomographic (CT) reconstructions were studied retrospectively in 14 patients with skull base fractures. Our aim was to assess the clarity of visualisation and pattern of these fractures. The reformations were obtained from 3 mm thick two-dimensional (2D) CT images. The 2D data stored on optical discs were retrieved and reformatted using the scanner's software. The 3D technique could demonstrate the presence of fractures as well as 2D images. It was of special value in defining the depth and extent of fractures in the floor of the cranial fossae. Undisplaced and displaced fractures could both be demonstrated. Fractures in the anterior fossa run diagonally towards the midline and then cross the cribriform plate of the ethmoid bone. Fractures of the middle fossa run obliquely anteroposterior. Fractures in the lamina papyracea and cribriform plate were difficult to reconstruct due to the thinness of these bones and threshold definitions. The volume of the 3D block determines the angles suitable for viewing the fractures. In spite of present technical difficulties, the 3D images are of greater anatomical and diagnostic value, particularly in anterior fossa fractures. There is no additional radiation risk to the patient, since reconstructions are made from routine 2D images.

Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury

A 100-month retrospective review was undertaken to identify the population characteristics of patients with both facial and cranial fractures and to establish the relationships between them. A 4.4% incidence of cranial fractures was found in the 882 patients with facial fractures. These patients tended to be males (85%) between the ages of 16 and 30 years (54%) who were involved in motor vehicle accidents (64%). Patients with midfacial fractures predominated (70%), and these injuries were most frequently associated with fractures of the frontal (38%), sphenoid (24%), or temporal (22%) bones. No relationship was noted between mandibular fractures and cranial fractures. Midfacial fractures were related to individual cranial bone fractures by sutural attachment. The presence of cranial fractures did not play a role in the development of complications associated with facial fractures.

Alternative approaches to pterygomaxillary separation

Pterygoid plate fractures, resulting from the pterygomaxillary separation in a Le Fort I osteotomy, may be associated with untoward fractures that extend to the base of the skull and orbit and which can lead to rare but significant complications. Five alternative approaches to the pterygomaxillary dysjunction were studied in 50 fresh cadavers. The results of this study show that the use of a curved Obwegeser osteotome to achieve the pterygomaxillary dysjunction should be abandoned, as it leads to an unacceptably high incidence of high-level pterygoid plate fractures at, or near, the base of the skull. The best results were obtained with a Stryker micro-oscillating saw.

Abducent nerve palsy following transverse fracture of the middle cranial fossa

Transverse sphenoidal fractures may be associated with a variety of skull base injuries and neural deficits. Among those nerve injuries, oculomotor palsies and particularly sixth cranial nerve palsy, are quite common. Blows on the side of the head in the squamous temporal region may run across the floor of the middle cranial fossa through the greater wing of the sphenoid in the transverse cranial axis. We report three cases of patients who had sustained craniofacial injury which included a transverse fracture of the middle cranial fossa through the sphenoid sinus, extending to the petrous apex and producing abducent, facial, and eighth nerve dysfunction. Spontaneous recovery from diplopia occurred in all cases within 4 months. The management of the patients and the patterns of transverse cranial base fractures and their associated clinical features are discussed.

Pterygoid plate fracture in Le Fort I osteotomy with and without pterygoid chisel: a computed tomography scan evaluation of 58 patients

The incidence of pterygoid plate fracture as determined by computed tomography (CT) scan is much higher than that determined at surgery. This observation is irrespective of whether a chisel is used to effect pterygo-maxillary separation.