Fronto-orbital Region Research Articles

A Case Report on Frontal Osteoma

A 13 years old boy admitted with the complaint of progressive exophthalmos and gradually decreasing vision on right eye, also occasional headache and deformity on the right fronto-orbital region. Radiological & clinical findings revealed a case of frontal osteoma in the right frontal sinus extending up to right frontal lobe, eroding right roof of the orbit. Complete excision of the tumor mass was possible surgically. Biopsy confirmed a case of osteoma. Below is a discussion on diagnosis & management of frontal osteomaPulse Vol.9 January-December 2016 p.45-48

Patient-specific biodegradable implant in pediatric craniofacial surgery

Surgical correction of premature fusion of calvarial sutures involving the fronto-orbital region can be challenging due to the demanding three-dimensional (3D) anatomy. If fronto-orbital advancement (FOA) is necessary, surgery is typically performed using resorbable plates and screws that are bent manually intraoperatively. A new approach using individually manufactured resorbable implants (KLS Martin Group, Tuttlingen, Germany) is presented in the current paper. Preoperative CT scan data were processed in iPlan (ver. 3.0.5; Brainlab, Feldkirchen, Germany) to generate a 3D reconstruction. Virtual osteotomies and simulation of the ideal outer contour with reassembled bony segments were performed. Digital planning was transferred with a cutting guide, and an individually manufactured resorbable implant was used for rigid fixation. A resorbable patient-specific implant (Resorb X-PSI) allows precise surgery for FOA in craniosynostosis using a complete digital workflow and should be considered superior to manually bent resorbable plates.

Single-Step Primary Reconstruction After Complex Fronto-Orbital Brown Tumor Resection Using Computed-Designed Peek Implant

The authors describe a patient with secondary hyperparathyroidism (HPT) who had develop- ment of a brown tumors (BTs) of the superior orbit and frontal calvarium with subsequent visual impairment. One-step surgery involving wide en-bloc resection of the entire tumor and immediate fronto-orbital reconstruction with a custom-made polyetheretherketone (PEEK) im- plant was planned. Using a PEEK implant a one-step reconstruction of the fronto-orbital region was achieved obtaining symmetry and good functional results, reducing operative time and avoiding donor site morbidity.

Modulating transcallosal and intra-hemispheric brain connectivity with tDCS: Implications for interventions in Aphasia.

Transcranial direct current stimulation (tDCS) can enhance or diminish cortical excitability levels depending on the polarity of the stimulation. One application of non-invasive brain-stimulation has been to modulate a possible inter-hemispheric disinhibition after a stroke. This disinhibition model has been developed mainly for the upper extremity motor system, but it is not known whether the language/speech-motor system shows a similar inter-hemispheric interaction. We aimed to examine physiological evidence of inter- and intra-hemispheric connectivity changes induced by tDCS of the right inferior frontal gyrus (IFG) using arterial-spin labeling (ASL) MRI. Using an MR-compatible DC-Stimulator, we applied anodal stimulation to the right IFG region of nine healthy adults while undergoing non-invasive cerebral blood flow imaging with arterial-spin labeling (ASL) before, during, and after the stimulation. All ASL images were then normalized and timecourses were extracted in regions of interest (ROIs), which were the left and right IFG regions, and the right supramarginal gyrus (SMG) in the inferior parietal lobule. Two additional ROIs (the right occipital lobe and the left fronto-orbital region) were taken as control regions. Using regional correlation coefficients as a surrogate marker of connectivity, we could show that inter-hemispheric connectivity (right IFG with left IFG) decreased significantly (p < 0.05; r-scores from 0.67 to 0.53) between baseline and post-stimulation, while the intra-hemispheric connectivity (right IFG with right SMG) increased significantly (p < 0.05;r-scores from 0.74 to 0.81). A 2 × 2 ANOVA found a significant main effect of HEMISPHERE (F(8) = 6.83, p < 0.01) and a significant HEMISPHERE-by-TIME interaction (F(8) = 4.24, p < 0.05) in connectivity changes. The correlation scores did not change significantly in the control region pairs (right IFG with right occipital and right IFG with left fronto-orbital) over time. Using an MR-compatible DC stimulator we showed that ASL-MRI can detect tDCS-induced modulation of brain connectivity within and between hemispheres. These findings might affect trial designs focusing on modulating the non-dominant hemisphere to enhance language/speech-motor functions.

Headaches attributed to airplane travel: a Danish survey.

BackgroundAirplane headache (AH) is a headache that occurs during take-off and landing. The pain is described as severe, unilateral, and located in the fronto-orbital region. This study aimed at investigating the incidence of AH among Scandinavian air-travelers, and to elucidating potential risk factors.MethodsAn online, Danish-survey was developed. The questionnaire consisted of 14 questions and was distributed through the Facebook-pages of Scandinavian-airlines and interest organizations. Participants reached the questionnaire through a web-link.ResultsOut of 254 responses, 89 noted that they suffered from headaches associated to airplane travel. Of the 89, 21 cases the headache was severe and limited to 30 min duration, as described in the ICH’s criteria of AH. The remaining 68 cases indicated that the headache lasted longer than 30 min. Our data demonstrated that High-Altitude Headache (HAH) is a risk factor for developing AH (p < 0.05). Triptans (19 %) and paracetamol (5 %) were reported effective to relieve AH.ConclusionThis study indicates that up to 8.3 % of the studied population suffered from AH, with a higher incidence in those with a history of HAH. Self-medication by triptans and paracetamol were reported effective for relieving AH.

A rare localization of pure dermoid cyst in the frontal bone

We report the case of an 84-year-old woman who came to our attention with right palpebral edema associated with pain in the omolateral fronto-orbital region. The patient underwent an MRI scan that revealed a rounded, extracerebral intradiploic cystic lesion with dyshomogeneous signal intensity. Computed tomography (CT) imaging was also performed with reformatted 3D reconstruction. Post-surgical histologic analysis confirmed the diagnosis of intradiploic dermoid cyst. We here report the case and discuss epidemiology, imaging features and work-up of this pathological entity.

Perception of children’s faces with unilateral coronal synostosis—an eye-tracking investigation

Premature unilateral coronal craniosynostosis results in distinctive cranial and facial abnormalities of varying severity, including orbital dystopia and an abnormal head shape. As the face is affected, these children may encounter stigmatization. To avoid this scenario, many parents elect for their child to undergo surgical correction. Laypeople's perception of children with either untreated or treated unilateral coronal craniosynostosis (UCS) has not yet been objectively evaluated. This study introduces eye tracking as an objective instrument in order to evaluate the perception of 14 children with coronal synostosis, both pre- and postoperatively. Age-matched healthy children served as a control group. Using standardized photos, the involuntary eye movements and the fixations of 30 unaffected laypeople were evaluated. In the untreated children, whose faces were characterized by striking orbital dystopia, the eyes drew more attention than those of the healthy children. The results of our study demonstrate that the operative correction of unilateral coronal synostosis results in the normalization of the asymmetry of the fronto-orbital region, whereas the C-shaped deformity of the midface, which is not addressed via surgery, subsequently attracts more attention. Eye tracking objectively evaluates both the perception of craniofacial abnormalities and the extent of the approximation of normality after surgical correction. We introduce eye tracking as an objective measurement tool for craniofacial abnormalities for the first time.

Correction of hypotelorism in isolated metopic synostosis

Surgical correction of trigonocephaly is performed by fronto-orbital reshaping and advancement. Some authors supplement the fronto-orbital remodelling with direct surgical correction of the hypotelorism, but the role of this step of the procedure has been questioned. At Sahlgrenska University Hospital, hypotelorism in metopic synostosis is treated with spring-assisted surgery (S) in children below 6 months of age and with fronto-orbital advancement with the interposition of a bone graft (BG) in the fronto-orbital region at higher age. The aim of the present study was to evaluate the anterior bony interorbital distance (BIOD) preoperatively and at follow-up in patients operated on with the two techniques and to compare the results with adequate control groups. Preoperatively, the patients affected by metopic synostosis had a significantly reduced BIOD compared to their respective controls (S group: 13.8 ± 1.6 (mean ± SD) mm vs 18.6 ± 1.4 mm, p < 0.001, BG group: 14.7 ± 1.0 mm vs 18.8 ± 1.4 mm, p < 0.001). At 3 years follow-up, BIOD was improved in both groups, but only in the S group the mean BIOD did not differ from the control group (19.7 ± 2.9 mm vs 20.2 mm ± 1.3 mm, p = 0.3). In the BG group the BIOD was still significantly different between patients and controls (17.6 ± 1.8 vs 20.0 ± 1.1 mm, p < 0.001). Spring-assisted surgery performed before 6 months of age can normalise hypotelorism in metopic synostosis. Full correction in a large series of patients has now been achieved for the first time.

Paediatric craniofacial fibrous dysplasia: The Hospital for Sick Children experience and treatment philosophy

Craniofacial fibrous dysplasia is a benign developmental anomaly in which normal bone is replaced by fibro-osseous tissue. The aim of this study was to audit the patient population at a tertiary paediatric centre and report our treatment protocols. A retrospective chart review of all patients with craniofacial fibrous dysplasia treated at the Hospital for Sick Children between 1999 and 2010 was performed. The treatment algorithm used by our centre is presented. A total of 55 patient records were reviewed; 37 patients had sufficient documentation for study; 27 (16 male, 11 female) patients underwent surgery at our institution, of these patients, 26 had post-operative follow up of greater than one year (mean 41 months; median 24 months). Mean age at presentation was 9.9 years (median 10 years) and mean age of surgery was 13 years. Ten patients underwent surgery on the fronto-orbital region, 7 of the calvarium, 2 the skull base and 8 upon tooth-bearing bones. Fourteen cases underwent debulking surgery as their primary therapy whereas 13 patients had complete resection. Nine patients experienced recurrence and all but one case of these occurred in patients that underwent debulking therapy. When age of surgery is considered, total resection and reconstruction or debulking surgery after skeletal maturity has a lower recurrence rate (1/7 cases) than earlier surgery (8/16). Complete resection at any age and debulking surgery once skeletal maturity has been reached may be associated with lower recurrence rates than incomplete resections at an earlier age. Patients with McCune-Albright syndrome may benefit from repeated debulking procedures rather than complex resections and reconstructions.

One-step primary reconstruction for complex craniofacial resection with PEEK custom-made implants

PurposeReconstruction of large craniofacial defects has largely improved since custom-made implants have been developed in the past decade. For large lesions in fronto-orbital region (such as osteomeningioma), we applied a simple and reliable protocol to perform optimal primary reconstruction with PEEK (polyetheretherketone) specific implant at the same time of the resection. Material and methodsOur protocol is based on virtual preoperative surgery with a planned bone resection that allows engineering of a specific implant to accurately fit to the defect during the surgery. Thus tumour removal and optimal immediate reconstruction are performed easily in a single-step procedure. The use of navigation is required to perform accurate resection according to the planning. We report our experience in five patients requiring complex orbito-frontal reconstruction. ResultsPlanned resection was always achieved with accurate placement of the implant. Optimal orbital reconstruction is allowed and permits exophthalmos correction and orbital contour symmetry. No major complication was observed. ConclusionWe provide a simple one-step technique to reconstruct the orbit while achieving symmetric cosmetic and functional results, reducing operative time and avoiding donor site morbidity.

Surgical treatment of an anterior cranial fossa dural fistula

A 48-year-old man presented headaches in the last two months, and no neurological deficits. The computed tomography (CT) scan revealed an intraparenchymal hemorrhage localized in right frontal lobe. The magnetic resonance (MR) showed the lesion included middle frontal gyrus, fronto-orbital region and gyrus rectus (Fig 1) […]. Surgical treatment of an anterior cranial fossa dural fistula

Frontal Linear Scleroderma

Frontal linear scleroderma (also known as "en coup de sabre") is a congenital deformity characterized by a linear band of atrophy and a furrow in the skin that occurs in the frontal or frontoparietal area. The authors present a case of a 34-year-old woman with history of en coup de sabre. In different steps, volumetric restoration of the fronto-orbital region has been obtained by structural fat grafting technique. After 3 reconstructive surgeries, morphologic, functional, and aesthetic long-term results have been obtained.

Improved Correction of Supraorbital Rim Deformity in Craniosynostosis by the “Tilt” Procedure

Orbital rim deficits are a feature of metopic, unilateral coronal, and bilateral coronal craniosynostosis. Several procedures have been developed to address this issue, but relapse to the preoperative hypoplastic deformity and stunted growth of the fronto-orbital region are common. The authors describe a technique modification of the conventional lateral canthal advancement referred to as the orbital rim "tilt" procedure, which aims to preserve inferior bony support for the orbital rim and create projection with optimal proclination of the fronto-orbital complex.

Composite Fronto-Orbital Reconstruction Using a Subscapular Chimeric Flap

Composite defects of the fronto-orbital region represent a reconstructive challenge. Total autogenous reconstruction requires a thin pliable skin flap along with a bony component that can be osteotomized predictably. The thoracodorsal artery perforator/scapular bone chimeric flap provides a reliable single-stage method to cover difficult composite forehead defects where local options are unsuitable or have been exhausted. We present a patient with a traumatic fronto-orbital defect that has been successfully reconstructed using this flap. The report of this case illustrates well the versatility of the subscapular system as a donor site for difficult composite posttraumatic defects where tissue components need to be inset in a complex three-dimensional fashion.

Application of CAD/CAM Prefabricated Age-Matched Templates in Cranio-Orbital Remodeling in Craniosynostosis

Infants with craniosynostosis involving the metopic and coronal sutures require cranio-orbital reshaping to correct craniofacial dysmorphologic feature and to improve facial balance. Currently, surgical techniques to create a balanced fronto-orbital region are based on the surgeon's subjective approach and artistic vision in creating a normal shape to the forehead. To date, the use of age-matched templates and computer-assisted design/computer-assisted manufacturing techniques in optimizing the outcomes of surgical intervention in this area have not been explored. The aim of this article was to describe the process of template generation and application based on age-matched controls using computer-assisted design/computer-assisted manufacturing technology and to present this application in 2 cases.

Why cluster headache is also called "suicide headache"?

Introduction: The cluster headache (CH) is characterized by attacks of excruciating unilateral headache, affecting mainly the fronto-orbital region associated with autonomic signs like lacrimation and conjunctival injection, eventually leading the patient to suicide. Objective: To report a case in which a patient committed self-harm during the crises of CH. Case report: An 85-year-old man was evaluated at the ambulatory of the Getúlio Vargas Hospital, Pernambuco. The patient was also subjected to a neurological examination and a cerebral computed tomography. The patient presented intense pain, with crises that last around three hours, in the right frontoorbital region with spread to the ipsilateral hemicranium. A relevant fact is that during one of the painful episodes the patient threw boiling water on the side of the pain, causing a second-degree burn on part of the head. Comment: The pain intensity in some cases may lead the patient to self-harm, so it is necessary that there be an early specialized approach with the objective of avoiding severe physical and psychological damages like the one that was described in this report.

Word frequency effects in the left IFG in dyslexic and normally reading children during picture naming and reading

Word frequency effects have been reported in numerous neuroimaging studies with typically reading adults, emphasising the role of the left inferior frontal gyrus (LIFG). Within LIFG, different cytoarchitectonic modules (areas 44 and 45) have been related to phonological vs. lexico-semantic processing, respectively. This fMRI study investigated the differential impact of word frequency on LIFG activation in reading and picture naming in primary school children with and without developmental dyslexia. All children showed the typical LIFG frequency effect in both tasks. The effect was comparable in a fronto-orbital region anterior-inferior adjacent to area 45. During reading but not picture naming, a second effect was observed in area 44. Here, the fMRI effect for lexical frequency was stronger for the dyslexic than the normal readers. These findings demonstrate the neural underpinnings of a selective deficit in dyslexic children in the graphemic input lexicon, whereas abstract lexical representations appear to be processed equally well in dyslexic and normally reading children. To conclude, the present fMRI study demonstrated differential impact of word frequency on LIFG activation in primary school children during reading but not picture naming. Apart from extending previous knowledge from studies with adults to childhood, the study sheds further light on a potential neural mechanism for deficient grapheme-to-phoneme conversion in dyslexic children.

Aesthetic Restoration of Fronto-orbital Deformity with Prefabricated Implant Utilizing Modeling Clay and Rapid-prototyping Technology

Skeletal deformity in the fronto-orbital region resulting from various problems can have significant aesthetic concerns. Restoring an aesthetically acceptable appearance relies most importantly on the restoration of a precise skeletal contour. Current surgical options for depression deformities or partial-thickness defects range from extensive corrective osteotomies to less complicated methods of onlay grafting with autogenous or alloplastic materials. Both methods have difficulties in providing a symmetric and smooth contour for predictable and reliable cosmetic results. Alloplastic implants provide another effective alternative and the success of the skeletal contouring correlates directly with the accuracy of the implant sculpture. Prefabricated methylmethacrylate implants, with the aid of modeling clay, computer imaging, and modern rapid-prototyping technologies, fits the depression deformity well and balances the skeletal contour. It provides plastic surgeons greater precision in customizing the implant, which ensures better predictability and reliability of cosmetic outcomes.

Long-Term Outcome of Fibrous Dysplasia: Reconstruction With Dysplastic Bone -Case Report-

A 10-year-old girl presented with facial asymmetry associated with bulging of the right fronto-orbital region with no symptoms. Computed tomography demonstrated enlargement of the right zygomatic, frontal, ethmoid, and sphenoid bones. Abnormal proliferation of the bone had obliterated the sphenoid, right frontal sinus, and right ethmoid sinuses. These radiological findings suggested right optic nerve compression due to fibrous dysplasia. Right optic canal decompression was performed. In preparation for recurrence, the resulting bone defect in the right orbital roof was reconstructed using the outer table of the split lesion bone. The removed frontal bone was divided into intact and lesioned parts, and the intact part was returned. The lesioned part was split and the outer table graft used to reconstruct the frontal region. A temporal musculopericranial flap was used to form a barrier between the opened ethmoid sinus and cranial cavity. A protrusion appeared on the left forehead 10 years later, and was shaved to improve the aesthetic appearance. The patient was followed up for a total of 23 years. The use of dysplastic bone involves the risk of recurrence, but the period of recurrence is delayed and the progression stops after adolescence, so the second operation involved only shaving for aesthetic appearance. This procedure is one of the treatments of choice because of easy reconstruction, easy revision, and good results.

Brain activation patterns of versive, hypermotor, and bilateral asymmetric tonic seizures

Patients who have seizure onset from different brain regions can produce seizures that appear clinically indistinguishable from one another. These clinically stereotypic manifestations reflect epileptic activation of specific networks. Several studies have shown that ictal perfusion single photon emission computed tomography (SPECT) can reveal propagated ictal activity. We hypothesize that the pattern of hyperperfusion may reflect neuronal networks that generated specific ictal symptomatology. All patients were identified who were injected with (99m)Tc-hexamethyl-propylene-amine-oxime (HMPAO) during versive seizures (n = 5), bilateral asymmetric tonic seizures (BATS; n = 5), and hypermotor seizures (n = 7) in the presurgical epilepsy evaluation between 2001 and 2005. The SPECT ictal–interictal difference image pairs of each subgroup were compared with image pairs of 14 controls using statistical parametric mapping (SPM 2) to identify regions of significant hyperperfusion. Hyperperfused regions with corrected cluster-level significance p < 0.05 were considered significant. We have identified a distinct ictal perfusion pattern in each subgroup. In versive seizure subgroup, prominent hyperperfusion was present in the frontal eye field opposite to the direction of head version. In addition, there was associated caudate and crossed cerebellar hyperperfusion. The BATS subgroup showed pronounced hyperperfusion supplementary sensorimotor area ipsilateral to the epileptogenic region, bilateral basal ganglia, and contralateral cerebellar hemisphere. The hypermotor seizure subgroup demonstrated two clusters of significant hyperperfusion: one involving bilateral frontomesial regions, cingulate gyri, and caudate nuclei, and another involving ipsilateral anteromesial temporal structures, frontoorbital region, insula, and basal ganglia. We have identified distinct hyperperfusion patterns for specific ictal symptomatology. Our findings provide further insight into understanding the anatomic basis of seizure semiology.