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CASE REPORT

ACOFS

VOL I ISSUE I

POST-TRAUMATIC FRONTAL SWELLING WITH PROPTOSIS AND DIPLOPIA Sabari R1, Singh SP2, Reddy N3

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ABSTRACT Craniorofacial trauma often manifests itself as a multisystem injury in 20-50% of the cases. Midface and zygomatic bone fractures are the most common occurring together in developing countries due to inadequate road traffic legislations while mandible fractures are common due to its most predominant position in face and also due to interpersonal conflicts/assaults. Neurosurgeons and oral & maxillofacial surgeons play a very vital role along with neurologists and ophthalmologists in managing a craniorofacial trauma patient. The emergency physicians must have the expertise to manage the situation and stabilize a patient with severe traumatic injuries of craniorofacial region.

Use the QR Code scanner to access this article online in our databse Article Code: ACOFS001 into the orbit, adjacent sinuses, and nasal cavity or through the skin. The mass may remain a simple mucocele containing mucus, or it may become secondarily infected, forming a pyocele. Frontal mucoceles may present with ophthalmic disturbances. They

Key words:Paranasal sinus, Visual loss, Proptosis. How to cite this Article:Sabari R,Singh SP, Reddy N,Post

Traumatic

Frontal

Swelling

Fig.1

with

can encroach on the orbit with ocular displacement

Propoptosis and Diplopia.Arch CranOroFac Sc

and proptosis. They are a common cause of long stand-

2013;1(1):1-5

ing unilateral proptosis[4]. Ocular motility distur-

Source of Support: Nil

bance, lid distortion, and perioccular pain is other important presentations. Patient with frontal sinus

Conflict of Interest:No

mucoceles presenting with proptosis, diplopia and

Introduction Frontal mucoceles are collections of inspissated mucus which occur when there is obstruction to the outflow of the frontal sinuses[1]. The obstruction may be due to congenital anomalies, infection, trauma, allergy, neoplasms or surgical procedures in the nose[2,3]. With continued secretion and accumulation of mucus, the increasing pressure causes atrophy or erosion of the bone of the sinus, allowing the mucocele to expand in the path of least resistance. This may be

epiphora are presented in this case report. Case Report A 36-year-old Indian man presented with progressive painless proptosis of the right eye for two years [Figure. 1]. He had history of traumatic injury at frontal region at left side 16 years back with small swelling on same region. He also complained of diplopia and epiphora since 2 months in left eye. The left globe was proptosed by 4 mm compared to the fel-

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POST-TRAUMATIC FRONTAL SWELLING WITH PROPTOSIS AND DIPLOPIA

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and 0.3 in the left. Fundoscopy showed choroidal elevation superiorly, with choroidal folds over the macula in the right eye. The right fundus was normal. Orbital ultrasonography revealed a retrobulbar cystic mass arising superiorly, indenting the posterosuperior aspect of the left globe. Computerized tomography scan (CT) showed a right intraorbital extraconal isodense mass causing gross downward and outward displacement of the globe [Figure. 2]. A magnetic resoFig.2

nance imaging (MRI) of the orbit was suggested to better define the lesion. MRI showed that the mass was a mucocele arising from the frontal sinus causing inferior displacement of the orbital roof resulting in proptosis. The patient underwent left fronto- ethmoidectomy with frontal sinus reconstruction by mucosa and muscular patch with evacuation of the mucocele and reconstruction of orbital roof. Intraoperative mucocele was completely extradural and invaded into orbital roof and extended upto retro orbital region on left side

Fig.3

[Figure.3 and 4]. Postoperatively at six months, there was complete resolution of the proptosis and the patient was asymptomatic. Discussion A gradual onset of unilateral proptosis poses a clinical diagnostic challenge included in the differential diagnoses are eye disease, retrobulbar orbital tumour, inflammatory pseudo tumour, sinus tumour, metastatic lesion and mucoceles of the paranasal sinuses. Progressive unilateral painless proptosis of gradual

Fig.4

onset should make one suspicious of a mucocele involving the paranasal sinuses, the frontal and eth-

low eye and was displaced 3 mm inferiorly and tem-

moid sinuses being the two most common locations[4-

porally. It was firm to retropulsion. The ocular motili-

8]. This is especially so if there is accompanying

ty of his left eye was restricted in upgaze and horizon-

diplopia, orbital or forehead pain, and epiphora, which

tal gaze, with diplopia in all positions of gaze. The

are frequently the presenting symptoms of mucoceles.

pupils were equal and reactive. The optic discs were

The symptoms are produced by pressure against the

not swollen but the cup-disc ratio was 0.5 in the right globe and mechanical interference with its motility. Archives of CraniOroFacial Sciences, August -September 2013;1(1):1-5 2


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POST-TRAUMATIC FRONTAL SWELLING WITH PROPTOSIS AND DIPLOPIA

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The proptosis is usually non-axial with the globe being

mucosa which appears as a region of low attenuation.

displaced away from the site of the mucocele. The

The extent of bone destruction is also better appreciat-

amount of proptosis may fluctuate when the patient

ed on CT. MRI is able to show mucoceles but it can

develops a common cold or has inflamed sinuses[4].

sometimes be misleading because inspissated mucus

There may be an associated history of sinus or nasal

within the sinus may be mistaken for an aerated cavi-

pathology or injury. The patient may occasionally

ty[14]. With MRI, there is also a lack of contrast

complain of blurred vision and image distortion.

between the cortical bone margins of the orbit and

Visual loss, field changes[9] and optic atrophy[10] are

adjacent air in the sinuses, making evaluation of the

late manifestations which occur when the proptosis

orbital walls difficult. In general, if the clinical fea-

becomes marked. The cause of visual loss is varied. It

tures are highly suggestive of a sinus mucocele as the

may be due to direct compression of the optic nerve in

cause of proptosis, a CT scan of the orbit may be the

the orbit[6] ,a vascular or inflammatory process

first imaging choice. However, MRI may provide

involving the optic nerve[6,11,12] refractive errors

additional information in the examination of the orbit

induced by the indentation on the globe, exposure ker-

and may be the preferred imaging technique if other

atopathy or secondary glaucoma. The ophthalmic

soft tissue tumours causing proptosis cannot be

manifestations of the patient described are not uncom-

excluded. Orbital ultrasonography is another useful

mon presentations of frontal mucoceles. Patient pre-

imaging tool as it helps to determine whether the

sented with painless, non-axial proptosis with restric-

lesion is a cystic or a solid mass. The definitive treat-

tion of ocular movements and diplopia as well. There

ment of mucoceles is primarily surgical. The aim of

was also the possibility of optic nerve involvement

surgical management is to reestablish adequate

causing deterioration of visual acuity and colour vision

drainage of the sinus without producing cosmetic or

as in the patient. Other known complications of frontal

functional deformity. In addition, the lining of the cyst

mucoceles include erosion of the anterior wall; result-

may be removed and the sinus obliterated with soft tis-

ing in a tender fluctuant mass beneath the periosteum

sue like abdominal fat. This can be accomplished by

of the frontal bone[5]. Erosion of the posterior wall

an lesion is a cystic or a solid mass external open

may produce complications such as epidural abscess,

obliterative procedure or the more cosmetically

meningitis, subdural empyema and brain abscess.

appealing osteoplastic flap technique[2,15-18].

Rarely, cranial nerve palsies may also occur[13]. The

Prompt surgical therapy is needed to achieve good sur-

classic radiographic appearance of a mucocele is gen-

gical outcome.

eralized thinning and expansion of the sinus walls and

Conclusion

there may also be evidence of sinus disease as well as

Frontal mucoceles may occasionally present with oph-

bony erosions. The mucocele usually appears homog-

thalmic manifestations such as proptosis. Being

enous and airless. Although plain radiographs do

benign and curable, early recognition and management

reveal the lesion, CT scans are much better in delin-

of mucoceles is of paramount importance. A high

eating the extent of the lesion and its relations to other

index of suspicion and appropriate radiological studies

surrounding structures. They can differentiate the high

are necessary for the diagnosis of mucocele. Open sur-

attenuated regions of mucus from the surrounding

gical and Transnasal endoscopic evacuation are viable

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POST-TRAUMATIC FRONTAL SWELLING WITH PROPTOSIS AND DIPLOPIA

surgical option to solve this problem.

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Pathogenic problems and case reports. Neuro-oph thalmol 1981; 1:273-80.

REFERENCES

12.Fujitani T, Takahashi T, Asai T. Optic nerve

1. Nugent G R, Sprinkle P, Byron M. Sphenoid sinus

disturbance caused by frontal and frontoethmoida

mucoceles. J Neurosurg 1970; 32:443-51. mucopyoceles. Arch Otolaryngol 1984; 110:267-9. 2. Stiernberg C M, Bailey B J, Calhoun K H, Quinn F B. Management of invasive frontoethmoidal sinus mucoceles. Arch Otolaryngol Head Neck Surg 1986; 112:1060-3.

13.Ehrenpreis S J, Biedlingmaier J F. Isolated third nerve palsy associated with frontal sinus mucocele. Neuro-ophthalmol 1995; 15:105-8.

3. Diaz F, Latchow R, Duvall A J 3rd, Quick C A,

14.Toriumi D M, Sykes J M, Russell E J, Morganstein

Erickson D L. Mucoceles with intracranial and

S A. Sphenoethmoidal mucocele with intracranial

extracranial extensions. J Neurosurg 1978; 48:284-

extension: Radiologic diagnosis. Otolaryngol Head

8.

Neck Surg 1988; 98:254-7.

4. Alberti P W, Marshall H F, Black J I. Fronto-ethmoidal mucocele as the cause of unilateral proptosis. Br J Ophthalmol 1968; 52:833-8. 5. Abrahamson I A, Baluyot S T, Tew J M, Scioville G. Frontal sinus mucocele. Ann Ophthalmol 1979; 2:173-8.

15.Chandler J R Jr. Mucoceles: Their diagnosis and treatment. J Fla Med Assoc 1960; 46:825-31. 16.Goodale R L, Montgomery W W. Experiences with osteoplastic anterior wall approach to frontal sinus. Arch Otolaryngol 1958; 68:271-83. 17.Iliff C E. Mucoceles in the orbit. Arch Ophthalmol

6. Avery G, Tang R A, Close G C. Ophthalmic manifestations of mucoceles. Ann Ophthalmol 1983; 15:734-7.

1973; 89:392-5. 18.Gross W E, Gross C W, Becker D, Moore D, Phillips D. Modified transnasal endoscopic

7. Natvig K, Larsen T E. Mucocele of the paranasal

Lothrop procedure as an alternative to frontal sinus

sinuses: retrospective clinical and histological

obliteration. Otolaryngol Head Neck Surg 1995;

study. J Laryngol Otol 1978; 92:1075-82.

113:427-34.

8. Kaufman S J. Orbital mucopyoceles. Two cases and a review. Surv Ophthalmol 1981; 25:253-62. 9. Fazakas A. A contribution to the symptomatology of a mucocele in ophthalmology. Ophthalmologica

Authors 1.Reza Saberi MD Registrar, Dept. of Neurosurgery Kashan University of Medical Sciences, UK

1953; 25:175-82. 10.Mortada A. Radiography in mucocele of the

2. Singh S.P MCh

frontal sinus. Am J Ophthalmol 1967; 64:1162-

Senior Registrar

7.

Dept. of Neurosurgery,

11.Imachi J. Rhinogenous retrobulbar neuritis:

Bhopal ,M.P. India

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3. Reddy N, MD Junior Resident, Department of Radiology, NMCH, Andhra Pradesh, India Correspondence Address Reza Saberi MD Registrar, Dept of Neurosurgery Kashan university, UK Email – saberi@yahoo.co.in

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Original Research

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INFLUENCE OF ALCOHOL IN CRANIOROFACIAL INJURIES Yasseen Aly Yasseen1, M.Akheel2 ABSTRACT Alcohol consumption has become a part of daily life for people ranging from lower to upper class individuals. However, addiction of alcohol can lead to impaired judgment and undue physical harm. This study shows that alcohol intoxication plays a major role in craniorofacial trauma and incidence of road traffic accidents is extremely high in India. A strict law has to be reinforced to ban/decrease the usage of alcohols for welfare of the society.

Keywords:Alcohol,Road Traffic Accident. How to cite this Article:Yasseen YA,Akheel M Influence of Alcohol in Craniofacial Injuries.Arch CranOroFac Sc 2013;1(1):6-8 Source of Support: Nil Conflict of Interest:No Introduction Alcohol consumption has become a part of daily life for people ranging from lower to upper class individuals. However, addiction of alcohol can lead to impaired judgment and undue physical harm. Most of the road traffic accidents happen due to alcohol influence in developing and developed countries. Most of these patients suffer from craniorofacial injuries with or without head injuries.[1] Adverse effects of alcohol are intoxication which causes neurologic imbalance and instill violence and aggression among individuals who have consumed it. It also leads to increase in road traffic accidents, interpersonal conflicts and falls. [2, 3]Craniorofacial skeletal region is the most common

www.acofs.com Use the QR Code scanner to access this article online in our databse Article Code: ACOFS002 targeted area in alcoholic individuals. The severity of injuries varies from the quantity and time of alcohol consumed. Literature shows a well established correlation between alcohol and craniorofacial injuries. [4, 5] Injuries occurring in these patients ranges from multiple facial fractures and severe head injuries which cause death immediately or leave the individual for poor prognosis. In developing and developed countries road traffic accidents remains the most major problem which is further aggravated by alcohol intoxication. The government of India has found some success to ban alcohol selling without license and educate the public about its adverse effects. In this article, we have accessed the relation between alcohol intoxication and degree of severity of craniorofacial injuries. [4,5,6] Material and Method A study of 91 patients, who came to department of emergency between the period of March 2011 to March 2012 was conducted.Out of 91 patients, 57 patients were found to be intoxicated with alcohol and suffered massive craniorofacial injuries. Alcohol use was documented as per the patient or attender because alcohol levels in the blood could not be checked due to legal constraints. Out of these 57 patients were found to be intoxicated with alcohol. Out of these 50 were male and 7 were females. The age group was found to be between 19 to 55 years. The most common alcohol intoxicated related mode of injury was road traffic accident (47.1%), interpersonal conflicts (25.8%), falls (21.5%) and miscellaneous (5.6%). Among cranioro-

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INFLUENCE OF ALCOHOL IN CRANIOROFACIAL INJURIES

facial injuries, the most common fractures bone was mandible followed by zygomatic complex and other bones. Out of 57 patients , 27 patients sustained multiple fractures of craniorofacial skeleton , 9 patients had severe head injuries, 6 patient sustained C-spine fractures, 13 patients sustained skull fractures and 2 patients died due to severe head injuries and other concomitant injuries. Soft tissue injuries were found in 53 patients. [2] Discussion The economical costs, ease of availability and acceptance of alcohol as a representation of social status have contributed to its more major cause for various incidents like road traffic accidents and assaults. [5] Recent literature shows a decline in alcohol intoxicated injuries in developing and developed countries as a result of improved road traffic regulations, improved car safety mechanism, posing a ban on non licensed alcohol venders along the highways, conduction a public awareness campaigns. In India, a strong action has been taken by the government and serious punishments has been posed for drunk and driving which led to decline of the accidents but still it pose one of the major cause for accidents in developing and developed countries.[7-9] In conclusion, this study shows that alcohol intoxication plays a major role in craniorofacial trauma and incidence of road traffic accidents is extremely high in India. A strict law has to be reinforced to ban/decrease the usage of alcohols for welfare of the society. References 1. Oikarinen et al "Frequency of alcohol-associated mandibular fractures in northern Finland in the 1980s." Alcohol and Alcoholism ;1992:189-193. 2. Chrcanovic, Bruno Ramos, et al. "Facial fractures: a 1-year retrospective study in a hospital in Belo

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Horizonte." Brazilian Oral Research;2004:322328. 3. El-Maaytah, Mohammed, et al. "The effect of the new 24 hour alcohol licensing law? on the incidence of facial trauma in London." British Journal of Oral and Maxillofacial Surgery;2008: 460-463. 4. Hyder, Adnan A., et al. "The impact of traumatic brain injuries:a global perspective." NeuroReh abilitation; 2007: 341-353. 5. Ferrando, Josep, et al. "Impact of a helmet law on two wheel motor vehicle crash mortality in a southern European urban area." Injury prevention ;2000: 184-188. 6. Shapiro, Andrew J., et al. "Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse." Injury; 2001: 353-356. 7. Johnston, J. J. E., and S. J. McGovern. "Alcohol related falls: an interesting pattern of injuries." Emergency medicine journal ; 2004: 185-188. 8. Rivara, Frederick P., David C. Grossman, and Peter Cummings. "Injury prevention." New England journal of medicine;1997: 543-548. 9. Driving, Reducing Alcohol-Impaired. "Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving." 2001. Authors 1. Yasseen Aly Yasseen DDS Junior Resident, Dept of Oral & Maxillofacial Surgeon, Cairo university , Egypt 2. M Akheel (MDS) Junior Registrar Dept of Oral and Maxillofacial Surgery Dr. MGR University, Chennai , India

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Correspondence Address Yasseen Aly Yasseen Junior Resident, Dept. of Oral & Maxillofacial Surgery, Cairo University ,Egypt Email- yaseen@gmail.com

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Review Article

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CRANIOROFACIAL TRAUMA - RADIODIAGNOSIS Zambrano JCR1

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ABSTRACT Clinical examination of Craniorofacial injuries are often limited in patients with trauma to the head and neck region due to obscuration by overlying edema, hematoma, hemorrhage, and soft-tissue injury. Craniorofacial injuries require accurate and prompt diagnosis for management. For Proper clinical examination and treatment plan, high resolution radiographs are always essential which will indirectly contribute to render a good medical care to the patients.

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Keywords:Radiographs, 3D CT Scan How to cite this Article:JCR Z Craniorofacial Trauma-Radiodiagnosis.Arch CranOroFac Sc 2013;1(1):9-10. Source of support: Nil Conflict of interest:No "RADIOGRAPHS ARE LIKE ROAD MAPS FOR MEDICAL HEALTH CARE SPECIALIST" Clinical examination of Craniorofacial injuries are often limited in patients with trauma to the head and neck region due to obscuration by overlying edema, hematoma, hemorrhage, and soft-tissue injury. Craniorofacial injuries require accurate and prompt diagnosis for management. Unlike the conventional scans which were used before giving minimal/poor radiological information high-resolution computed tomography (CT) scan and three-dimensional CT scan offer valuable information for complete and thorough evaluation of the craniorofacial fractures.[1, 2,3] In this article, we discuss the imaging techniques which are available for Craniorofacial trauma and the need for it. Largest number of admissions in hospitals is due to craniorofacial fractures. Morbidity results when initial diagnosis and management are inaccurate, delayed, and suboptimal. High-resolution CT

Article Code: ACOFS003 imaging have replaced conventional radiography for the proper evaluation of craniofacial trauma because of its widespread availability, affordable costs and fast imaging capability.[4,5] CT can also be with less hazardous positioning of injured trauma patients to prevent further damage to the injured organs. Presently, the requirement of a preliminary 4-film screening series of radiographs is questioned. A single 30degrees occipitomental view and postero anterior view of skull can determine accurately which patients should have CT scanning. Axial and coronal CT scan sections at 他 mm slice thicknesses are essential for complete evaluation of the craniorofacial structures. Direct coronal CT scanning is preferred, but if not feasible due to cervical spine injury, thin-section axial helical scans should be performed that allow for reformations in the coronal plane with optimal resolution. [5,6] A study undertaken recently in cadaver heads showed high sensitivity and specificity for identifying clinically significant craniorofacial fractures on reformatted images in trauma patients. We suggests that reformatted coronal images may be able to replace dedicated direct coronal craniorofacial scanning that are precluded in many trauma patients due to suspected or associated cervical spine injury.[3, 6, 7] Three-dimensional (3D) CT imaging is useful as an adjunct to high-resolution thin-section CT and allows clinicians to visualize the number of fracture fragments and their relationship to one another. [2] Three-dimensional images has favored significantly in the evaluation of severe craniorofacial trauma in 29% of patients. These images appear superior in localization of complex fractures involving multiple planes, in the evaluation of fracture displacement and

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CRANIOROFACIAL TRAUMA - RADIODIAGNOSIS

dislocation, and in the proper assessment of facial symmetry. Also, 3D imaging is essential for fabrication of bone grafts used in complex Craniorofacial reconstructions. However, this does not supplant twodimensional (2D) imaging for detection of craniorofacial fractures, especially for the deeply involved facial structures. [8-10] The role of Magnetic Resonance Imaging in the evaluation of craniorofacial trauma is limited but may provide complementary information in special circumstances, such as orbital trauma of posterior floor, associated traumatic aneurysms, carotico-cavernous sinus fistula, etc. Therefore to have a proper clinical examination and treatment plan, high resolution radiographs are always essential which will indirectly contribute to render a good medical care to the patients. References 1. Schuknecht, Bernhard, and Klaus Graetz. "Radiologic assessment of maxillofacial, mandibular, and skull base trauma." European radiology;2005: 560-568. 2. Exadaktylos, Aristomenis K., et al. "The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma center." The Journal of Trauma and Acute Care Surgery ;2005:336-341. 3. Thai, K. N., et al. "The role of computed tomographic scanning in the management of facial trauma." The Journal of Trauma and Acute Care Surgery ;1997: 214-218.

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facial surgical planning: experimental validation in vitro." Journal of Oral and Maxillofacial surgery ;1999: 690-694. 6. Gillespie, J. E., et al. "Three-dimensional reformations of computed tomography in the assessment of facial trauma." Clinical radiology; 1987: 523-526. 7. Fox, Lee A., et al. "Diagnostic performance of CT, MPR and 3DCT imaging in maxillofacial trauma." Computerized medical imaging and graphics ;1995: 385-395. 8. Scarfe, William Charles. "Imaging of maxillofacial trauma: evolutions and emerging revolutions." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology; 2005: S75-S96. 9. Brant, William E., and Clyde A. Helms, eds. Fundamentals of diagnostic radiology. Wolters Kluwer Health, 2012. 10.Hemmy, David C., D. J. David, and Gabor T. Herman. "Three-dimensional reconstruction of craniofacial deformity using computed tomography." Neurosurgery; 1983: 534-541.

Correspondence Address Zambrano JCR , M D Registrar Dept. of Neurosurgery University of Andes, Venezuela Email id : jennycaroline@hotmail.com

4. Hussain, K., Wijetunge, D. B., Grubnic, S., & Jackson, I. T. A comprehensive analysis of craniofacial trauma. The Journal of Trauma and Acute Care Surgery:1994; 36(1): 34-47. 5. Cavalcanti, Marcelo GP, John W. Haller, and Michael W. Vannier. "Three-dimensional computed tomography landmark measurement in cranioArchives of CraniOroFacial Sciences, August-September 2013;1(1):9-10

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Review Article

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CRANIO MAXILLOFACIAL INJURIES Demanding Aspect in Emergency Department www.acofs.com

Perwez Aslam1, Gazal Parveen2 ABSTRACT Craniorofacial trauma often manifests itself as a multisystem injury in 20-50% of the cases. Midface and zygomatic bone fractures are the most commonly occurring injuries together in developing countries due to inadequate road traffic legislations while mandible fractures are common due to its most predominant position in face and also due to interpersonal conflicts/assaults. Neurosurgeons and oral & maxillofacial surgeons play a very vital role along with neurologists and opthalmologists in managing a craniorofacial trauma patient. The emergency physicians must be an expertise to manage the situation and stabilize a patient with severe traumatic injuries of craniorofacial region. K e y w o r d s : C r a n i o f a c a i a l Tr a u m a , C e r v i c a l Spine,Glasgow Coma Scale. How to cite this Article:Aslam P, Parveen G Craniomaxillofacial Injuries:Demanding Aspect in EmergencyDepartment.Arch CranOroFac Sc 2013;1(1):11-13. Source of Support: Nil Conflict of Interest:No Minimum time on scene, Maximum treatment in route, Make a plan soon. Craniorofacial trauma often manifests itself as a multisystem injury in 20-50% of the cases. Midface and zygomatic bone fractures are the most commonly occurring injuries together in developing countries due to inadequate road traffic legislations while mandible fractures are common due to its most predominant position in face and also due to interpersonal conflicts/assaults.[1,2] Out of these, 25% of women who

Use the QR Code scanner to access this article online in our databse Article Code: ACOFS004 sustain maxillofacial injuries are due to domestic violence. There is higher incidence of cervical spine injuries in cases of midface and mandibular fractures. Fracture of C1, C2 is due do midface fractures while fracture of C3 is due to bilateral mandibular fractures. Sometimes these maxillofacial injuries are associated with traumatic brain injuries which are high due to motor vehicle accidents.[2,3,4] There is also documented evidence that pediatric patients demonstrate a significant higher percentage of associated injuries (73%), as compared in adults (58%). A greater number of cranial injuries associated with maxillofacial injuries have been documented in the pediatric population (55%) than in the adult group (39%). The approach for the primary evaluation of the patient with craniorofacial injury starts with assessment of Glasgow coma scale (GCS).[4,5] Primary survey starts with Circulation, Airway and Breathing to maintain adequate oxygenation, ventilation and perfusion. Soft tissues of Craniorofacial region have a rich vascular supply which causes sufficient amount of blood loss for the patient to go in the state of shock. Maxillofacial fractures like Lefort can cause considerable bleeding episodes by damaging the underlying vessels manifesting itself as epistaxis and hematomas and deep neck injuries like carotid injuries can also worsen the condition of the patient.[5, 6-8] Primary assessment of the patient includes two main important things: Airway and Cervical spine assessment. Airway of the patient has to be evaluated first by the emergency physician.[2, 3] Patients with

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CRANIO MAXILLOFACIAL INJURIES Demanding Aspect in Emergency Department

maxillofacial injuries with underlying head injuries can lose their support of tongue which may fall back to the posterior wall of oropharynx leading to airway embarrassment. In these patients endotracheal intubation must be performed cautiously because of the possibility of underlying cervical spine injuries. Safe intubation has to be carried after stabilizing the cervical spine to prevent further damage and then stabilized by

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injury severity scale in craniomaxillofacial trauma." Journal of oral and maxillofacial surgery ;2006: 408-414. 4. Daffner, Richard H., et al. "Patterns of high-speed impact injuries in motor vehicle occupants." The Journal of Trauma and Acute Care Surgery ;1988: 498-501.

traction /hard cervical collars.[1, 3] Literature search revealed there is an incidence of 1% to 4% of cervical spine injuries associated with craniorofacial injuries.[2,3] After establishing the airway, if there is

5. Zargar, Moosa, et al. "Epidemiology study of facial injuries during a 13 month of trauma registry in Tehran." Indian Journal of Medical Sciences

an underlying head injury confirmed by computed tomography scan of brain and there is no time to carry out secondary survey, patient is taken in operation the-

6. Marshall, Kelley W., Bernadette L. Koch, and John C. Egelhoff. "Air bag-related deaths and serious

atre to evacuate/treat the head injury. If not so, secondary survey is carried on with clinical case history taking, like cause of the injury, past medical history, last oral intake and an organized protocol for performing the clinical examination of Craniorofacial region with expert specialists.[1, 3] Neurosurgeons and oral & maxillofacial surgeons play a very vital role along with neurologists and ophthalmologists in managing a craniorofacial trauma patient. The emergency physicians must be an expertise to manage the situation and stabilize a patient with severe traumatic injuries of craniorofacial region[9,10,11]. References 1. Gassner, Robert, et al. "Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years." Journal of oral and maxillofacial surgery;2004: 399-407. 2. Elahi, Mohammed M., et al. "Cervical spine injury in association with craniomaxillofacial fractures." Plastic and reconstructive surgery ;2008: 201-208.

;2004: 109.

injuries in children: injury patterns and imaging findings." American journal of neuroradiology ;1998: 1599-1607. 7. Ferrando, Josep, et al. "Impact of a helmet law on two wheel motor vehicle crash mortality in a southern European urban area." Injury prevention ;2000: 184-188. 8. Gassner, Robert, et al. "Cranio-maxillofacial trauma: a 10 year review of 9543 cases with 21067 injuries." Journal of Cranio-Maxillofacial Surgery ;2003: 51-61. 9. Bagheri, Shahrokh C., et al. "Facial trauma coverage among level-1 trauma centers of the United States." Journal of Oral and Maxillofacial Surgery ;2008: 963-967. 10. Sinclair D, Schwartz M, Grass J, et al: A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries. JEmerg Med ;1988;(6):109. 11. Turvey TA: Midfacial fractures: A retrospective analysis of 593 cases. J Oral Surg; 1977;(35):887

3. Bagheri, Shahrokh C., et al. "Application of a facial Archives of CraniOroFacial Sciences, August-September 2013;1(1):11-13

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Authors 1. Perwez Aslam,M D Senior Registrar, Dept. of Neurosurgery,Kuwait 2. Gazal Parveen,M D S Postgraduate resident, Dept. of Oral & Maxillofacial Surgery, Lucknow, India Correspondence Address Perwez Aslam, M D Senior Registrar, Dept of Neurosurgery Ibn Sina hospital,Kuwait

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Case Series

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BLIND NASAL INTUBATION IN CRANIOROFACIAL TRAUMA K.R.DavidThakaran1, Siddharth.M2, Sagar Lodhia Sudan3 ABSTRACT Restricted mouth opening presents one of the greatest challenges to the anesthetist for endotracheal intubation and ventilation. Awake blind nasal intubation has been one of the finest and favored techniques for intubation in previous decades for restricted mouth opening patients. A coordinated team approach, monitoring and adequate counseling of the patient is mandatory for the airway management to carry out a safe surgical procedure Keywords:Blind Nasal Intubation,ET Tube. How to cite this Article:Thakaran KRD,M S,Sudan SL Blind Nasal Intubation in Craniorofacial Trauma.Arch CranOroFac Sc 2013;1(1):14-16 Source of Support: Nil Conflict of Interest:No Restricted mouth opening presents one of the greatest challenges to the anesthetist for endotracheal intubation and ventilation. Awake blind nasal intubation has been one of the finest and favored techniques for intubation in previous decades for restricted mouth opening patients[1,2]. In this article, we describe the difficult airway management of 5 patients with craniorofacial trauma with awake blind nasal intubation. 5 patients ( 4 male & 1 female) diagnosed with various craniorofacial injuries were operated for open reduction and internal fixation. All patients were intubated with awake blind nasal intubation with a same expert anesthetist. Out of 5 patients, 3 patients had 8- 12mm of mouth opening and 2 patients had below 6 mm of mouth opening. All patients underwent a preanesthestic evaluation for intubation and ventilation. Same procedure was followed for all 5 patients. Thyromental distance was measured for all patients. Out of 5 patients , 4 patients had 5-

www.acofs.com Use the QR Code scanner to access this article online in our databse Article Code: ACOFS005 6cm and 1 patient had 3-4 cm. On clinical examination of the nasal cavity, there was no obvious deviation of nasal septum, no hypertrophy of turbinates, or any nasal polyps or masses. Preoperative investigations were within normal limits. Chest X ray showed no deviation of trachea. Awake BNI was planned for the surgical procedure. Preoperatively nasal decongestant, 0.05% xylometazoline was instilled in bilateral nostrils. Inj. Midazolam 1gm was induced intravenously to allay anxiety and favour smooth intubation and vitals were monitored. Bilateral laryngeal block was given with 2% lignocaine. The nostril was lubricated with 2% lignocaine jelly, and awake BNI was tried. A 6.5 mm internal diameter, cuffed endotracheal tube was introduced through patient’s nares and entered in the pharynx. Upon reaching nasopharynx, breathing sound was listened by the anesthetist at the endotracheal tube connector which was acting as a guide for the tube advancement and then the tube was further introduced while larynx was pushed gently to the right side externally. In some patients, in first attempt the trachea could not be identified and intubated and the ET tube was withdrawn and readjusted with positioning of head, extending it and pressing down at the thyroid cartilage. The position of the tube was marked by the coughing of the patient, inability to speak, hearing of breath sounds and with chest auscultation. Vitals were monitored which were stable. The ET tube was fixed in place. Anesthesia was administered and maintained by the cycle of halothane 1% and nitrous oxide 60%, oxygen 40% and vecuronium 2.5mg. Ventilation

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was maintained with respiratory rate of 16 per min. Adequate mouth opening is a prime requirement for safe and comfortable intubation and ventilation for anesthetist. Certain conditions like trismus caused in craniorofacial trauma and other conditions does not always ensures for an easy intubation. In these patients limited options are available for managing the airway[3]. Better options like orotracheal intubation, Laryngeal Mask Airway (LMA), Intubating LMA (ILMA), combitube are not useful in this reduced mouth opening patients[4]. Options are limited to blind nasal intubation, retrograde intubation using a guide wire, fibreoptic laryngoscopy and finally tracheostomy. Out of these, the safest and most widely used technique in previous decades was awake blind nasal intubation which is practiced by senior anesthetists presently[5]. Due to the latest advancement like fibreoptic laryngoscopy the management of airway in trismus patients has become safe, effective and a routine in established hospitals in urban areas in the present decades. Hospitals in urban and semi urban areas where the fibreoptic laryngoscope is not available or feasible, awake blind nasal intubation is the one of the best and cost effective technique. So the anesthetist performing this technique has to be efficient and well trained to perform awake BNI to manage difficult airway. Other options like retrograde intubation and tracheostomy can be performed by every present generation anesthetist. Some anesthetist prefers to perform fibreoptic nasal endoscopy prior to nasal intubation to visualize the nasal cavity, nasopharynx and orophraynx, and trachea for any deformities[6]. In all our 5 cases, awake blind nasal intubation was done without any preoperative fibreoptic laryngoscopy by the same expert anesthetist. Awake blind nasal intubation is a one of the best alternative technique for management of difficult airway in patients having trismus. It remains

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the technique of choice in rural, semi-urban places or conditions where expensive instruments like fibreoptic laryngoscopes are not available. It is cost effective, less traumatic technique with a high success rate in the hand of expertise anesthetist. A coordinated team approach, monitoring and adequate counseling of the patient is mandatory for the airway management to carry out a safe surgical procedure. REFERENCES

1. Benumof JL: Management of the difficult airway with special emphasis on awake tracheal intubation. Anesth 1991; 75:1087-110. 2. Francis A, Neidorf C Blind awake nasal intubation. Anaesth Prog 1977;24:15-17 3. Riazi J. The difficult paediatric airway. Anesthesiology Clinics of North America 1998; 16: 707-923. 4. Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Amer Emer Med 1981; 10: 142-4. 5. Thomas J Gall, Airway management. Miller RD Ed Millers Anaesthesia; 6th Ed, Elsevier Churchil Livingstone, 1620-45. 6. Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anaesth 1996; 8: 136-40.

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AUTHORS 1. K.R. David Thakaran , MDS Assistant Professor, Dept. of Oral & Maxillofacial Surgery, Govt .Dental College Cochin, India 2. Siddharth M , MDS Junior Registrar, Dept.of Oral & Maxillofacial Surgery Hyderabad, A.P. India 3. Sagar Lodhia MD Junior Registrar, Dept. of Oral & Maxillofacial Surgery, Al Khartoum Bahry Khartoum, Sudan , Africa Correspondence Addresses Sagar Lodhia, MD Junior Registrar, Dept. of Oral & Maxillofacial Surgery, Al Khartoum Bahry Khartoum, Sudan , Africa Email id: dr.sagar@hotmail.com

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Short Communication

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CraniOrofacial Trauma: The first law Shikha Bharadwaj1, Anuj Bhargava2

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ABSTRACT Trauma has been given the utmost importance in the field of medicine since ages and is still being the most common cause of mortality and disability worldwide. Every hospital must have a fully equipped trauma care unit, operation theaters and intensive care units to render a better care to trauma patients and also emergency medical services and specialist from all the medical specialties. Keywords:Trauma, First law How to cite this Article:Bhardwaj.S,Bhargava A,CraniOrofacial Trauma:The First Law.Arch CranOrofac Sc 2013;1(1):17-18 Source of Support: Nil Conflict of Interest:No "TRAUMA" is a Greek word, meaning wound caused due to physical injury by external sources.It is a mysterious word of all times most often leading to life threatening situations. It has been given the utmost importance in the field of medicine since ages and is still being the most common cause of mortality and disability worldwide.[1] Trauma is broadly classified as poly trauma, head trauma, facial trauma, chest trauma, extremity trauma, pelvic trauma and spine trauma. Trauma remains a multi disciplinary disease requiring participation of consultant expertise specialists including neuro surgeons, maxillofacial and reconstructive surgeons along with orthopedic surgeons.[2] The scenario of providing trauma care to the patients has change drastically over the last decade. The introduction of routine computed tomography with 3 dimensional scan and ultrasounds has facilitated non-operative management of blunt solid organ injuries.[3, 4] Having seen and operated many cases of craniorofa-

Use the QR Code scanner to access this article online in our databse Article Code: ACOFS006 cial trauma for years, we have seen a certain common things which we would like to share.Theses are the basic laws of trauma along with underlying principles used for management.We would talk regarding the first law of Trauma. The first law of trauma states that:Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem. [1, 2] Some examples: A 23 year old young male riding a bike without a helmet crashes to a tree and sustain multiple facial injuries with mild extradural hematoma which is managed conservatively and has an epileptic attack 3 years later. A spot in the abdomen with minimal bleeding episode after a blunt trauma is not a cyst; it is a laceration until proven otherwise clinically and radiologically. A patient found lying on the stairs with blood in his head did not have a stroke and then fall down. The possibility and susceptibility of trauma always comes first in a trauma patient. It is the job of the trauma surgeon who is expertise in their respective field to rule it out. The problems which are caused due to trauma are devastating and life threatening and must always be considered first and foremost and treated accordingly as per the plan. A trauma surgeon is a qualified, experienced and expertise in managing the trauma patient as well as planning the treatment within the golden hour period to save one's life[5]. Prevention of these injuries includes reinforcement of law in road traffic legislation, decreasing the speed limits of motor vehicles, reinforcement of wearing seat belts and helmets.[1,4,6] Every hospital must have a fully equipped trauma care unit, operation theaters and intensive care units to render a better care to trauma patients and also emergency medical services

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and specialist from all the medical specialties.[6] In Sehore , M.P., India this article we have shortly elaborated the assessment Email- shikha@gmail.com of craniorofacial injuries and the importance of trauma care centre in our country with our experience and also tried to highlight the first law of trauma. References 1. Gassner, Robert, et al. "Cranio-maxillo facial trauma: a 10 year review of 9543 cases with 21067 injuries." Journal of Cranio- Maxillofacial Surgery ;2003: 51-61. 2. Hussain, Karim, et al. "A comprehensive analysis o f craniofacial trauma." The Journal of Trauma and Acute Care Surgery;1994: 34-47. 3. Gillespie, J. E., et al. "Three-dimensional CT reformations in the assessment of congenital and traumatic cranio-facial deformities." British Journal of Oral and Maxillofacial Surgery ;1987: 171-177. 4. Gruss Joseph S. "Complex Craniomaxillofacial Trauma: Evolving Concepts in Management. A Trauma Unit's Experience-1989: Fraser B. Gurd Lecture." The Journal of Trauma and Acute Care Surgery ;1990: 377-383. 5. Becelli, Roberto, et al. "Craniofacial Trauma: im mediate and delayed treatment." Journal of Cran iofacial Surgery ;2000: 265-269. 6. Marciani, Robert D., and Arthur A. Gonty. "Princ iples of management of complex craniofacial trauma." Journal of Oral and Maxillofacial surgery;1993: 535-542. Authors Bharadwaj S, MDS Sehore , M.P., India Bhargava A,MDS Assistant Professor Dept.of Dental Surgery Index Medical College Indore,India Correspondence Address Bharadwaj S, MDS Archives of CraniOroFacial Sciences, August-September 2013;1(1):17-18

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