Naso-orbito-ethmoid Research Articles

Pattern of Ophthalmic Injuries in Patients With Maxillofacial Fractures at a Tertiary Care Centre in Central India.

Maxillofacial injuries are usually associated with ophthalmic injuries that may be mild to severe, and may even result in loss of integrity of the orbital skeleton and impairment of the visual apparatus. To evaluate the pattern of ophthalmic injuries associated with maxillofacial fractures in patients who reported to a tertiary care hospital, associated with a medical college in M.P, India. The records of patients who sustained ophthalmic injuries with maxillofacial trauma from 1st January 2012 to 31st January 2024 and reported to the Department of Dentistry of a tertiary care hospital were evaluated. The data related to demographic characteristics, aetiology of trauma, type of maxillofacial fractures and pattern of ophthalmic injuries were gathered and analysed. A total of 1575 patients with maxillofacial trauma reported to the institute during the study duration. The study sample comprised 1046 (66.41%) maxillofacial trauma patients who sustained ophthalmic injuries. Males were more commonly involved (85.85%) than females (14.15%). The commonly involved age group was 21-30 years with 34.32% of patients belonging to the age group. The most common aetiology was road traffic accidents, reported in 71.89% of patients. Zygomaticomaxillary complex (ZMC) fractures were evident in 73.52%, mandibular fractures in 50.19%, naso-orbito-ethmoidal (NOE) fractures in 19.41% and frontal bone fractures in 18.74% patients. Subconjunctival haemorrhage was seen in 79.83%, periorbital ecchymosis in 72.94% and periorbital oedema in 60.32% of cases. Retrobulbar haemorrhage was seen in 2.58%, traumatic optic neuropathy in 2.01% and retinal detachment in 0.86% of cases. Ophthalmic injuries were seen frequently in 66.41% of cases with maxillofacial trauma, particularly in zygomatic complex fractures (73.52%). The findings emphasise that the competency of maxillofacial surgeons plays a vital role in comprehending the severity and management of post-traumatic ophthalmic consequences in maxillofacial injuries. Also, ophthalmological evaluation in maxillofacial trauma, particularly involving the midface should be considered mandatory.

Secondary Reconstruction of Panfacial Fractures With Virtual Reality Surgical Planning Using Both Pre and Postreconstruction Scans.

Late secondary reconstruction is sometimes required in patients with suboptimal primary panfacial fracture repair. At this stage, it can be difficult to discern original facial architecture due to malunion and bony remodeling. By utilizing the original postinjury CT scan to complete fracture reduction in the virtual reality (VR) planning environment, the surgeon may attempt to recreate an "ideal" facial bony anatomy for patients. This technique was completed in 2 patients presenting with facial deformity secondary to malunited panfacial fracture. Each had a cone-beam CT (CBCT) scan taken at presentation and the initial postinjury CT scans were obtained. Fracture reductions were completed in VR to recreate the preinjury anatomy. The resulting model was overlaid with current anatomy to create surgical aids. The first patient, a 23-year-old man, presented with malunion of all bones of the midface. Cutting guides were designed for the Lefort 1 segment, left zygomaticomaxillary complex (ZMC), and naso-orbito-ethmoid (NOE) osteotomies. The second patient, a 30-year-old woman, had bilateral ZMC and subcondylar fractures, midface retrusion, and malunion of parasymphyseal fracture. A 2-stage procedure was planned, including an initial Lefort I and bilateral sagittal split osteotomy with midline wedge excision. To address malar projection, a second surgery was planned using custom MEDPOR midface implants for the NOE and zygomatic regions. Both patients were discharged home, and all surgical goals and esthetic objectives were achieved.

In- Versus Out-Fracture: A Novel Concept in Naso-Orbito-Ethmoid Injury.

A retrospective study. The Markowitz-Manson classification system categorizes nasoorbitoethmoid (NOE) fractures by severity of injury and remaining integrity of the medial canthal tendon. However, this system does not account for direction of bony displacement (in-fracture vs out-fracture), which can greatly affect symptomatology and management. We hypothesize that NOE fractures will present differently based upon their severity: Type I injuries are likely to present with medial nasal bone displacement (in-fracture), whereas Type III fractures will be more prone to lateral displacement (out-fracture). A retrospective review was performed for all patients with NOE fractures who were evaluated by the plastic surgery department at a level 1 trauma center over a 6-year period. Computed tomography data were evaluated to assess for directionality of fracture segment displacement. Frequencies of medial, lateral, and non-displacement across NOE types were compared by Chi-Squared Goodness of Fit and Fisher's Exact Tests. 111 patients met inclusion criteria. The patient population was 73.9% male and averaged 51.2years old. When bilateral fractures were counted independently, there were 141 cases in total: 115 Type I, 20 Type II, and 6 Type III. Type I fractures were most commonly in-fractured (48.7%), while Type III injuries were consistently out-fractured (100%) (p < .001). While Type II and III NOE fractures have dominated clinical focus, this study highlights the prevalence of impaction within Type I fractures. These findings advocate for a more comprehensive approach to the evaluation of Type I NOE fractures and their potential risks, including traumatic hypotelorism and nasal airway obstruction.

Evlauation of Fixation Techniques in Naso-orbito-ethmoidal Fractures: A Comparative Study

ABSTRACT Objective: Comparing fixation procedures for managing naso-orbito-ethmoidal (NOE) fractures. Methods: Group A (plate and screw fixation), Group B (Kirschner wire (K-wire) fixation), Group C (absorbable plate and screw fixation), and Group D (No fixation) were formed from 120 NOE fracture patients. The facial injury severity scale, visual analogue scale, CT scans, and clinical examination examined functional and cosmetic outcomes, complications, and postoperative stability. Results: The study found that plate and screw fixation (Group A) had the highest stability and aesthetic results, followed by absorbable plate and screw fixation (Group C). Conservative management (Group D) had the worst outcomes, while K-wire fixation (Group B) had good results but more complications. Results showed substantial differences in functional, aesthetic, complications, and postoperative stability between groups (P &lt; 0.05). Conclusion: Plate and screw fixation is the most successful and dependable approach for treating NOE fractures, with superior functional and aesthetic outcomes, reduced complications, and higher postoperative stability than K-wire fixation, absorbable plate and screw fixation, and conservative care. Absorbable plate and screw fixation may function instead of metal. Conservative care should be rare. Larger multicenter randomized controlled trials should corroborate these findings.

Surgical management of frontal bone and naso-orbito-ethmoidal fractures: a 7-year multi-center retrospective review

Frontal and naso-orbito-ethmoidal (NOE) fractures are rare but important injuries due to their anatomical complexity and proximity to vital structures. This study aims to describe the patient factors, procedural factors, and postoperative outcomes in the surgical management of these fractures. Retrospective review of patients aged 18 years or older who were surgically treated for these fractures at two Australian tertiary hospitals (2014-2020). Patient factors (demographics, mechanism of injury, fracture pattern, concomitant injuries); procedural factors (operation timing, surgical approach); and postoperative outcomes (complications, revision surgeries) were recorded. 60 cases were included (41 frontal; 29 NOE; 10 combined). Mean age was 37 (frontal) and 39 years (NOE). Most cases were male (87.8%; 75.9%). The most common mechanism was traffic accidents (29.3%; 34.5%). The most common associated facial fractures were Le Fort fractures (46.3%; 89.7%). The most common associated systemic injuries were brain injuries (36.6%; 34.5%). Mean operation timing was 13 days (frontal) and 11 days (NOE). Coronal flap was most commonly used (68.3%; 82.8%). Postoperative complication rates were 39.0% (frontal) and 37.9% (NOE). Three cases required revision surgeries. Further larger longitudinal studies are required to build knowledge and improve patient outcomes.

Characteristics of Maxilllofacial Trauma Patiens before and during the Covid-19 Pandemic in Oral and Maxilllofacial Surgery Department of Dr. Hasan Sadikin Hospital Bandung

Introduction: Prior to the COVID-19 pandemic, motor vehicle accidents, falls, physical assaults, and sports injuries were the main causes of maxillofacial trauma. The existence of interventions to prevent the COVID-19 pandemic resulted in home-centered social activities in the community. This also contributes to alterations in the aetiology of maxillofacial trauma that occur worldwide and may affect other characteristics of this entity. Methods:This is a retrospective study conducted at the Hasan Sadikin Hospital, Bandung, West Java, Indonesia, and was carried out in September–December 2022. The population of this study were maxillofacial trauma patients with diagnoses of vulnus (laceratum, schissum, punctum, and morsum), frontal, mandibular, maxillary fractures, orbit, naso-orbito-ethmoid (NOE), zygomaticus, and dentoalveolar fractures before the 2018–2019 pandemic period and during the 2020–2021 pandemic period at the Oral and Maxillofacial Surgery Department at RSUP Dr. Hasan Sadikin Bandung through the emergency department.The variables studied included age, gender, type of trauma, etiology, alcohol involvement, and management.The data are presented as frequency distribution and percentage in tabular and diagram. Results: During the 2018–2021 periods, there were 504 patients who experienced maxillofacial trauma before the COVID-19 pandemic, and this number has decreased to 216 patients during the COVID-19 pandemic. The majority of maxillofacial trauma experienced both before (n = 314; [62%]) and during (n = 166; [77%]) the COVID-19 pandemic was caused by motor vehicle accidents. Most of patients before the COVID-19 pandemic were aged 0–19 years (n = 230; [46%]), meanwhile, during the COVID-19 pandemic most patients were aged 20–39 years (n = 88; [41%]).Overall, there were no differences in sex characteristics, alcohol involvement, type of maxillofacial trauma, or treatment given before and during the COVID-19 pandemic. Conclusion: The existence of interventions to prevent the COVID-19 pandemic by imposing Large-Scale Social Restrictions (PSBB) has resulted in modifications to community social activities that are centered in the home. This factor contributed to some differences in the characteristics of maxillofacial trauma patients at the Oral and Maxillofacial Surgery Department in Hasan Sadikin Hospital before and during the COVID-19 pandemic. Keywords: Maxillofacial trauma, Characteristics, COVID-19

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

D77. In-fracture and Out-fracture: Novel Conceptions of Nasoorbitoethmoid Injury

PURPOSE: Nasoorbitoethmoid (NOE) fractures are commonly categorized by the Markowitz-Manson classification system, which grades severity of injury by degree of comminution and involvement of the medial canthal tendon. However, this system does not account for directionality of bony injury, which may impact clinical findings. We propose these fractures may be conceived as either in-fractured, resulting in nasal airway obstruction, or out-fractured, resulting in traumatic telecanthus. METHODS: A retrospective review was conducted of all patients with NOE fractures referred to plastic surgery at a tertiary academic medical center from 2017—2022. Radiographic data (CT) were evaluated to assess for directionality of NOE segment involvement. Frequencies of in-fracture and out-fracture across NOE type were compared by chi-squared test. RESULTS: Among 57 adults, 73 NOE fractures were identified with 39.7% (29) as Type 0 (non-displaced), 43.8% (32) as Type I, 12.3% (9) as Type II, and 4.1% (3) as Type III. Type I fractures were significantly associated with in-fracture (p < 0.0001), whereas Type III fractures were more likely out-fractured (p = 0.02). Type II fractures were not significantly associated with either presentation (p = 0.32). CONCLUSION: We discover that Type I NOE fractures more frequently present with in-fracture, whereas comminuted injuries such as Type III are typically out-fractured. Further study will validate these findings in a larger cohort and correlate radiography with clinical symptoms.

Local Approaches for the Reconstruction of Frontal and Naso-Orbito-Ethmoidal (NOE) Fractures: Presentation of a Clinical Case and Literature Review

Naso-orbito-ethmoidal (NOE) fractures are considered a challenge in reconstruction, due to the anatomical structures involved, such as the medial canthal ligament and the lacrimal apparatus [1], which leads to a complex functional and aesthetic compromise. For surgical access to the area, the use of the coronal, Lynch-Howarth, glabellar “open sky”, “gull wings” and a combination of the last two are described. However, the severity of the trauma and mainly the neurological compromise of the patient will dictate the choice of the approach that allows functional and comprehensive repair of the affected region. In cases where there is no neurological compromise and it is not necessary to carry out a subcranial approach, the use of local approaches is justified, providing adequate visibility and direct access to the fractured region, allowing an adequate reduction and placement of fixing material. A clinical case of anterior frontal sinus wall fracture and NOE fracture are presented, performing the combination of the gull-wing and open-sky approach, described as butterfly wings, achieving adequate visibility and reconstruction.

Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons.

Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports. This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians. The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded. Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports. Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOEand ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.

Prophylactic Intraoperative Nasolacrimal Duct Intubation in Surgical Treatment of Facial Fractures-Is There a Role?

Nasolacrimal duct (NLD) damage is associated in the majority of type II and III naso-orbito-ethmoid (NOE) fractures. 1 Our study aims to investigate the efficacy and safety of prophylactic NLD intubation in the setting of facial fractures, by comparing incidence of postoperative epiphora and wound infection. A retrospective matched control study was conducted on all patients with surgically treated facial fractures from 2008 to 2013 ( n = 280) (IRB ref number: DSRB 2013/01198). Patients with the following fracture types were included: NOE ( n = 16), frontal sinus ( n = 2), Le Fort II/III ( n = 8), and > 1 type ( n = 48). All patients in this study were included with the intention to treat. The study group comprised patients who were intubated, while the control group patients were not intubated. Each group had 37 patients matched for age, gender, fracture type, and injury type. A single oculoplastic surgeon skilled in lacrimal surgery performed the procedure for all intubated patients. Patients with more severe and complex facial fractures were intubated with bicanalicular Crawford stents. Postoperative epiphora and infective complications (both facial wound and dacryocystitis) were assessed at 1, 3, 6, and 12 months. There was no significant difference in incidence of either postoperative epiphora ( p = 0.152) or wound infection ( p = 0.556) comparing both groups. Reduced incidence of postoperative epiphora in the study group is statistically not significant and does not support the need for prophylactic intubation. If radiographic evidence of NLD disruption or regurgitation seen on syringing on the NLD intraoperatively is present, intubation is safe and efficacious only if performed by an expert.

Isolated Medial Maxillary Buttress Displacement in Naso-Orbito-Ethmoid Fractures: A Surgical Indication to Resolve Nasal Airway Obstruction.

The aim of this study was to present a case series emphasizing low medial maxillary (pyriform) buttress displacement in naso-orbito-ethmoid (NOE) fractures as an operative indication, in the absence of the typical NOE surgical indications (medial canthus displacement, midface bony comminution, nasal bone collapse, and orbital indications), to prevent nasal airway obstruction. Five cases of minor NOE fractures are reviewed, where only the low medial maxillary buttress was displaced. The typical surgical indications for NOE repair were absent. In each case, the pyriform buttress was medially and posteriorly displaced, creating nasal airway obstruction in each patient. The medial canthal tendons were all nondisplaced, there was no diplopia, and the other 2 cardinal buttresses (infraorbital rim and nasofrontal junction) were minimally displaced or greensticked. In the acute setting, patients were treated with open reduction and internal fixation. With delayed presentation, septorhinoplasty or osteotomy and fixation were used. Among the patients who had adequate follow-up, nasal airway obstruction was resolved. This series suggests that, in NOE fractures with isolated displacement at the medial maxillary buttress, nasal airway obstruction should be considered an operative indication (independent of the classical indications) in order to prevent or resolve nasal airway obstruction.

Facial Fractures Related to Soccer.

Soccer is one of the most popular sports in the world. Despite the concept that soccer is not a violent game, it can lead to several injuries in amateur and professional settings, including facial fractures. Previous studies of facial fractures in soccer were all retrospective and, to date, no prospective studies are available in the literature.The authors performed a comprehensive literature search using the terms "soccer" AND "facial fracture" OR "craniofacial fracture" and "football" AND "facial fracture" OR "craniofacial fracture" and retrieved 693 articles. After applying inclusion and exclusion criteria, 11 articles were included in the present study.A total of 647 patients had suffered facial trauma, with a male-to-female ratio of 63.7:1. The patients' mean age was 27.3 years.The articles reported 670 fractures as follows: 219 (32.7%) in the zygoma, 197 (29.4%) in the nasal bone, 153 (23.6%) in the mandibula, 54 (8.0%) in the orbital wall, 12 (1.8%) in the frontal sinus, 10 (1.5%) in the alveolar bone, 3 (0.4%) in the maxilla, 3 (0.4%) in a Le Fort pattern, and 1 (0.1%) in a naso-orbito-ethmoid (NOE) pattern.Sports are a frequent cause of maxillofacial trauma and are responsible for 9.2% to 33.2% of such injuries. Soccer is a contact sport more associated with lower-limb injuries, but with a significant rate of facial fractures. As soccer is a popular sport played without facial protection and involving high-intensity movements and contact, the prevention of facial fractures related to this sport is crucial to improve the players' safety.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center

A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Nasoorbitoethmoid fractures in a tertiary care hospital of eastern India: A prospective study.

Purpose:The purpose of this study was to report on the pattern of occurrence of nasoorbitoethmoid (NOE) fractures in Odisha and the various factors that influence their distribution.Methods:The study period was from January 1, 2016 to December 15, 2017. After approval from the Institutional Ethics Committee, all patients diagnosed with naso-orbito-ethmoid fractures reporting to the department of OMFS and Level-1 trauma centers were included in the study. Sociodemographic data along with the etiology and type of fracture were mentioned. Associated injuries to other body parts were noted. Open reduction was possible only in five cases of NOE fractures. The treatment plan including the operative approach and postoperative results was evaluated.Results:A total of 1192 patients with facial fracture were seen, of which 52 (4.36%) patients had NOE fractures. Males far outnumbered females in a ratio of 9:1. Thirty-three patients (63.46%) had unilateral NOE fracture, while the rest 19 (36.54%) had bilateral NOE fracture. Sixteen (30.76%) cases were classified as Type I, 35 (67.30%) as Type II, and 1 (1.92%) as Type III. Road traffic accidents were the most common cause of NOE fractures (69%), followed by fall (17%) and assault (10%). The most common neurological injury to be associated with NOE fractures was pneumocephalus (29%), followed by diffuse axonal injury (8%). Telecanthus (100%) was found to be the primary clinical feature in patients of NOE fracture, followed by a depressed nasal bridge (92%). Fracture of the nasal bone was invariably associated with NOE fracture. Complications observed due to untreated NOE fractures included a shortened and retruded nose, shortened palpebral fissures, telecanthus, and enophthalmos.Conclusion:Contemporary management of NOE complex fractures demands precise diagnosis and immediate surgical management with anatomic reduction and rigid fixation of the involved bone segments. With an improvement in socioeconomic status and increased awareness among maxillofacial surgeons, hopefully, a greater number of NOE fracture patients will avail the benefits of open reduction in future.

An Endonasal Incision Adds a Second Vector of Manipulation During Percutaneous Reduction of Fractures Involving the Frontonasal Region.

A case report. To describe a modification of percutaneous reduction of frontal sinus and/or naso-orbito-ethmoid (NOE) fractures, adding an endonasal intercartilaginous incision to provide a second vector of manipulation. Case report with particular attention paid to surgical technique, followed by a brief review of relevant literature. Technique: A Carroll-Girard screw is used to engage the thickest part of the anterior wall of the frontal bone through a stab incision just superior to the frontonasal junction. An endonasal intercartilaginous incision is then made and a Cottle elevator is introduced to manipulate the fracture from the inferior aspect of the frontonasal junction. The percutaneous screw and the endonasal elevator provide perpendicular vectors for manipulation, thereby improving ability to reduce fractures when percutaneous traction alone is not successful. The technique is described here in a patient with anterior table frontal sinus fractures combined with posteriorly displaced Markowitz type 1 NOE fractures. While percutaneous reduction of frontal sinus fractures has been previously described, this report adds a subtle but important modification both in indication and technique for optimizing reduction while maintaining surgical simplicity and minimizing morbidity.

Motor Vehicle Collision Injuries: An Analysis of Facial Fractures in the Urban Pediatric Population.

Motor vehicle collisions (MVC) are a leading cause of unintentional death and injury in the US pediatric population. Compliance with prevention measures such as seatbelts and child safety seats varies considerably with patient demographics. In this study, the authors examine facial fracture secondary to MVC in an urban pediatric population. A retrospective chart review was performed of all facial fractures as a result of MVC in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. Seventy-five patients met inclusion criteria for the authors' study. Mean age was 14 years old. Common fracture sites included orbital, mandible, nasal bone, and frontal sinus. Patients were more likely to incur fracture of the zygoma, orbit, nasal bone, frontal sinus, and nasoorbitoethmoid (NOE) if involved in an MVC compared to all other etiologies. Common concomitant injuries included traumatic brain injury, intracranial hemorrhage, and skull and long bone fractures. Open reduction and internal fixation with titanium plates was the most common surgical procedure indicated. Motor vehicle collisions related injury has significant health implications in the urban pediatric population. Orbital, zygoma, and nasal facial fractures and TBI are injuries commonly associated with MVC. The facial fractures are likely due to lack of proper utilization of safety equipment and airbags. Development of effective prevention techniques relies heavily on analysis of injury patterns and management strategies.

Abstract QS10: Zygomaticomaxillary Complex Fractures Associated With Naso-orbito-ethmoid Fractures In Pediatric Patients: A 25-year Experience At The Johns Hopkins Children’S Center

Purpose: Naso-orbito-ethmoidal (NOE) fractures associated with ipsilateral ZMC fractures are more challenging injuries than ZMC fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. Because of differences in the craniofacial skeleton between children and adults, it is important to characterize combined ZMC-NOE fractures in children specifically, especially given that this injury pattern in adults leads to poorer long-term outcomes. This study investigated the etiology, treatment, and outcomes of combined ZMC and NOE fractures versus isolated ZMC fractures in pediatric patients. Methods: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with ZMC fractures. Patient data/outcomes were derived from the medical record and comparatively investigated between (1)combined ZMC-NOE and (2)isolated ZMC fracture cohorts. Results: Forty-nine patients had ZMC fractures in our 25-year study period, of whom forty-six had adequate clinical documentation and follow up. Seventeen of these patients had ipsilateral NOE injuries associated with their ZMC fracture. Both patient groups (isolated ZMC fractures versus combined ZMC and NOE fractures) were similar in terms of demographics. However, patients with combined ZMC-NOE fractures had longer median hospital lengths of stay than patients with ZMC fractures alone (9 vs. 5.5 days), and a greater proportion of patients with combined ZMC-NOE fractures required more extensive surgical approaches with coronal incision (57.1% vs. 11.8%, p=0.007). Approximately 88.2% of patients with combined ZMC-NOE fractures suffered complications versus 31.0% of patients with isolated ZMC fractures. Furthermore, patients with combined ZMC-NOE fractures had greater incidence of postoperative facial deformity than those with ZMC fractures alone (adjusted odds ratio 6.72, p=0.032). Enophthalmos (41.2%), orbital dystopia (29.4%) and midface growth restriction (35.3%) were the most common postoperative deformities in patients with combined ZMC-NOE fractures, and were observed disproportionately in these patients compared to patients with isolated ZMC fractures. In fact, midface retrusion was seen exclusively in patients with combined ZMC-NOE fractures who had deciduous dentition. Conclusion: This is the largest longitudinal study of combined ZMC-NOE fractures in pediatric patients. Our results demonstrate that high impact trauma can cause NOE fractures in association with ZMC fractures relatively commonly in this patient population. This injury pattern was found to cause significantly greater postoperative complications and deformity than isolated ZMC fractures alone, possibly due in part to inadequate surgical reduction in the context of a more complex fracture. Thus, pediatric patients presenting with this facial fracture pattern require greater attention at the time of operative repair to ensure adequate bony reduction, possibly through use of low-dose intraoperative imaging and custom splints. Furthermore, these patients require more extensive clinical follow-up and monitoring given a greater risk for long-term morbidity.

Our experience of submental intubation: a reliable alternative to elective tracheostomy in maxillofacial trauma

Objective: The aim of this study was to evaluate retrospectively the frequency, indications, and outcome of submental intubation in maxillofacial trauma patients.Methodology: This retrospective study was performed at our maxillofacial surgery department. Retrospective data were collected from electronic patient records and patients’ operation notes from 1st June 2013 to 30th April 2018. All patients who had submental intubation performed irrespective of age and gender were included. Indications, intraoperative / post-operative course, any complications and esthetic results were evaluated.Results: During the period of study from 1st June 2013 to 30th April 2018, a total of 253 patients were operated under general anesthesia for various maxillofacial injuries at our hospital. Out of 253 operated patients, 185(73.1%) were males and 68(26.9%) were females with mean age of 32.7 years. A total of 7 submental intubations were performed. Out of these, 2 patients had panfacial trauma, 3 had comminuted Lefort II and III fractures and 2 had comminuted nasoorbitoethmoid (NOE)/ frontal complex fractures. No intraoperative complications were recorded. Postoperatively, one patient had persistent orocutaneous fistula with salivary leakage which was managed conservatively and healed within 4 weeks after surgery.Conclusions: Submental intubation is a simple, safe and fast alternative to tracheostomy for operative airway management in maxillofacial trauma patients.&#x0D; Received: 18 Oct 2018Reviewed: 20 Oct 2018Accepted: 30 Oct 2018&#x0D; Citation: Luqman U, Qayyum MU, Tasneem S, Ullah K, Khan M, Khan J. Our experience of submental intubation: a reliable alternative to elective tracheostomy in maxillofacial trauma patients. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S113-S117

&lt;p&gt;Submental Intubations in Panfacial Fractures&lt;/p&gt;

IntroductionAirway management in patients with panfacial fracture remains a challenge to anesthesiologists and surgeons. Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management.MethodsThe descriptive retrospective study was carried out and evaluated the outcomes of submental intubation in the management of panfacial fracture, complex maxillary or mandible fracture associated with nasal bone fracture and naso-orbito-ethmoid (NOE) fracture. The medical records of 23 patients who received submental endotracheal intubation were reviewed at UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal from March 2014 to December 2018. The following parameters were evaluated: mode of trauma, time required for intubation, accidental extubation, accidental perforation of the pilot balloon during its insertion, period of hospital stay, post-operative complications, such as the healing of submental scars both intraorally and extraorally.ResultsThe submental intubation was successfully done in all patients with minimal obvious post-operative complications. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident (69.56%). The mean time required for intubation was 8.43 (±0.84) minutes. No accidental extubations occurred. Accidental perforation of the pilot balloon was seen in one patient (4.35%) during tube manipulation which was managed successfully by changing the tube. The healing of submental scars was uneventful intraorally and extraorally in almost every case. The mean period of hospital stay in patients with submental intubation was 7.95 (±1.49) days.DiscussionSubmental intubation is an effective and safe method as it is not associated with complications of tracheostomy during management of panfacial fracture, NOE fracture and craniofacial fracture. In addition, it does not interfere with IMF during intraoperative period.