Sinus Fractures Research Articles

A Study on Outcomes of Surgical Treatment of Depressed Skull Fractures

Introduction: Trauma is a significant issue in both industrialized and developing nations. A significant risk factor for death in the young population is head injury Objective: To assess the outcomes of surgical treatment of depressed skull fractures Methodology: The current study was prospective study was done at Neurosurgery department of Khyber teaching Hospital Peshawar. The study duration was one years from March 2022 to March 2023. Causes of the depressed skull fracture, time since the injury, the kind of fracture, the location of the fracture, the reason for the fracture, the clinical state, and the CT scan results were noted. All patients had CT scans. DSF greater than 5 mm, disfiguring cosmetic fractures, and sinus fractures were surgically treated. The whole set of data was examined using SPSS 23.00. Results: In our study, totally 80 patients were enrolled. The male patients in our study were 58 (72.5%) whereas female patients were 22 (27.5%). In the outcomes based on GCS, completely recovered patients were 58 (72.5%) patients, 11 (13.75%) were moderately disabled, 8(10%) severely disabled whereas 2(2.5%) patients were demised. Conclusion: Trauma from depressed fractures is common in neurosurgical wards. One of the most important variables influencing outcome prediction is the neurologic state as indicated by the Glasgow coma scale. About two-thirds of patients who undergo surgical therapy of depressed skull fractures get successful results while one- third of patients are still classified as having severe disabilities. Complications, including death, are common after a depressed skull fracture. Keywords: Outcome; surgical treatment: depressed skull fractures

Assessment of Panfacial Fractures in the Pediatric Population

Purpose Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population. Patients and Methods We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected. Results We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival—or before arrival—at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died. Conclusions Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.

Reevaluating the Utility of Maxillary Sinus Opacification as a Screening Tool for Facial Bone Fracture a Decade After Its Original Analysis.

In 1997, Lambert and colleagues demonstrated that the absence of sinus fluid on head CT essentially excludes a fracture involving the sinus walls. Our purpose is to reevaluate this association utilizing the current standard of imaging technology. With improved image resolution, we aim to reassess whether the sensitivity and specificity of the “clear sinus sign” are improved or worsened. Furthermore, the current standard of care is to obtain a CT of the facial bones along with a head CT when facial trauma is suspected, so we also analyzed the association of the "clear sinus sign" with nasal bone and mandible fractures. We identified 629 facial bone CT scans performed on adult patients in the emergency department between July 2012 and May 2013. They were retrospectively analyzed by three reviewers for the presence of facial bone fracture and/or fluid opacification of at least one paranasal sinus (as defined by either complete sinus opacification or an air-fluid level - circumferential mucosal thickening was considered the absence of fluid). We found that sinus opacification was 98.8% specific for facial bone fracture but only 44.7% sensitive. However, for complex facial fractures, such as zygomaticomaxillary complex, orbital, and sinus fractures, the lack of sinus fluid is significantly more sensitive at 91%. Therefore, our results for complex facial fractures are congruent with those of the previous studies conducted by Lambert, et al. and Lewandowski, et al. However, we also demonstrate that sinus opacification is not specific for nasal bone or mandibular fractures.

Periorbital Subcutaneous Emphysema

Forty years old male was admitted with fever, cough and breathlessness since five days. Examination revealed signs of pleural effusion on left side of chest. Chest X-Ray showed left sided pleural effusion and left middle zone consolidation. Pleural fluid analysis suggested empyema. Patient was managed with intravenous antibiotics and left-sided inter-costal tube drainage. A day after thoracostomy patient developed swelling around eyes and thoracostomy site. Diffuse crepts were palpable around eyes, left side of chest and neck (Figure 1). CT confirmed the diagnosis of subcutaneous emphysema around eyes and chest wall. Swelling disappeared with conservative management within next three days (Figure 2). Periorbital emphysema is mostly due to disruption in the integrity of orbital boundaries because of trauma and subsequent orbital and sinus fractures. Less frequently follows dental surgeries. As a result of continuity of facial planes it can rarely occur as a result of spread from neck and chest subcutaneous tissue.

Severe pneumocephalus after penetrating injury to the lumbar spine

Introduction: Pneumocephalus is air or gas located in the intracranial cavity. Head trauma is the most common cause of pneumocephalus, with the majority of cases resulting from sinus and basilar skull fractures. A small number of case reports have been published describing pneumocephalus after cervical and thoracic penetrating injuries. To our knowledge, we report the first case of severe pneumocephalus in a patient with multiple penetrating stab wounds to the lumbar spine. Case Report: A healthy 21­year­old male presented to the trauma service with multiple stab wounds to the chest and lumbar spine after being assaulted. Computed tomography scans demonstrated severe pneumocephalus and pneumorrhachis. The patient had neurological deterioration and repeat head scans revealed worsening pneumocephalus. Myelography revealed a cerebrospinal fluid leak and thus warranted neurosurgical intervention to repair a dural tear. The patient made a full recovery without any neurological sequelae. Conclusion: Pneumocephalus caused by penetrating spinal trauma is exceedingly rare, especially to the lumbar spine and an extensive review revealed no cases in the literature. Our patient’s mechanism of trauma along with his clinical symptoms and radiographic images led to his timely diagnosis, avoidance of tension pneumocephalus and allowed for the most appropriate interventions for a full neurological recovery. The common etiologies, symptoms, diagnostic methods and treatment options relevant to this case will be reviewed.

The Clinical Significance of Pneumorachis: A Case Report and Review of the Literature

: Pneumorachis is a relatively rare phenomenon, where air enters the spinal canal. Because of its rarity, evaluation and management of this condition is poorly understood. This study describes a case of pneumorachis and performs a review of the current literature to understand the common causes, associated pathologies, presenting neurologic symptoms, treatment options, and neurologic outcomes for patients who develop pneumorachis. : The evaluation and management of a patient with pneumorachis who presented to our institution is described. In addition, a literature review of the Medline and Pubmed databases was conducted. The information collected from each study included the number of cases, proposed cause, associated findings, therapeutic interventions, and outcome. : A total of 50 patients from 42 studies were identified. Pneumorachis typically occurred after injury to the respiratory system and was often associated with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. This condition could also be seen after traumatic brain injury, especially with skull base and sinus fractures. Less common causes included primary spinal sources, visceral injuries, and fulminant infections. In most cases, pneumorachis was not associated with any spinal cord symptoms and typically resolved by addressing the underlying cause. : This review demonstrates that intraspinal air is typically benign and resolves with conservative therapies. However, it should be realized that in a rare number of cases, pneumorachis can cause symptoms of cord compression and may even require decompressive surgery. Therefore, prompt evaluation and diagnosis remain important.

Post-traumatic pneumocephalus

A 79-year-old male presented to the emergency department after a facial trauma because of a mechanical fall 3 h prior with no history of loss of consciousness. The patient had Parkinson’s disease and atrial fibrillation (AF), and was on treatment with acetylsalicylic acid for AF. The family reported that he was dependent for all basic daily activities and had mild cognitive deterioration. Physical examination showed that he was lethargic, but oriented, bradykinetic, and had gait and balance difficulty. No headache or confusion was reported. All cranial nerves were intact, and there were no motor or sensory deficits. He had superficial lacerations in the nasal and frontal regions. Nasal and ocular orbit X-rays were taken, showing nasal fracture and pneumocephalus (Fig. 1). Computed tomography scan confirmed pneumocephalus and multiple craniofacial fractures (Fig. 2). After a week of observation and prophylactic antimicrobial therapy during which there was no clinical deterioration, the patient was discharged. At follow-up 5 weeks later, the patient was at his clinical baseline. Repeated imaging showed progressive resolution. Fig. 1 X-ray showing nasal and orbital fractures and pneumocephalus Fig. 2 Large right pneumocephalus compressing right frontal lobe and widening interhemispheric space. There are also air bubbles in basal cisterns and cerebellar fissures bilaterally Pneumocephalus is the presence of air in the cranial vault. It is usually associated with neurosurgery, barotrauma, basilar skull fractures, sinus fractures, nasopharyngeal tumor invasion and meningitis [1, 2]. Headache and altered consciousness are the most common symptoms [3]. Tension pneumocephalus can occur and is a neurosurgical emergency [4]. Plain X-rays can diagnose pneumocephalus, but CT scan is the diagnostic modality of choice [5]. A classical CT sign of tension pneumocephalus is the “Mount Fuji sign”: the massive accumulation of air that separates and compresses both frontal lobes and mimics the profile of the large volcano in Japan. In our case, the air only compressed the right frontal lobe. Most cases of pneumocephalus resolve spontaneously, and conservative management should be provided. Nonoperative management involves oxygen therapy, keeping the head of the bed elevated, prophylactic antimicrobial therapy (especially in post-traumatic cases), analgesia, frequent neurologic checks and repeated CT scans.

Tension pneumocephalus: a rare complication after hyperbaric oxygen therapy

The study aimed to describe a patient with multiple skull bone fractures and a cerebrospinal fluid (CSF) leak who received hyperbaric oxygen therapy (HBOT). A 40-year-old man presented with subdural hemorrhage, skull bone fractures, facial bone fractures, sinus fractures, and CSF leakage after a one-story fall. He received HBOT as an adjunctive treatment to reduce brain edema and increase oxygen availability in brain tissue. Tension pneumocephalus developed after HBOT. Bur hole drainage was performed emergently to relieve the tension pneumocephalus. Cranioplasty and repair of skull base fracture were subsequently performed. The patient was discharged in a vegetative state. We proposed a possible mechanism by which tension pneumocephalus developed after HBOT sessions in this patient. Pneumocephalus, untreated skull base fracture, and CSF leakage should be considered contraindications to HBOT.

Traumatic Bitemporal Hemianopia

A 45-year-old male pedestrian was struck by a motor vehicle moving at high speed. Upon initial assessment, the patient scored a 3T on the Glasgow Coma Scale. The patient suffered multiple facial and sinus fractures, a right orbital wall fracture, and a depressed open frontal skull fracture with visible brain parenchyma. Due to the nature of the brain injury, the patient was taken to the operating room emergently for a right frontal craniectomy. The patient required prolonged hospitalization followed by transfer to a rehabilitation facility.Six weeks after the accident, the patient underwent an extensive neuro-ophthalmologic evaluation. At that time, visual acuity was 20/200 in both eyes. On visual field testing, a bitemporal hemianopia was noted. Ophthalmoscopic examination revealed bilateral temporal disc pallor, right greater than left. Neuroimaging demonstrated damage to the optic chiasm. Although rare, head trauma may cause a bitemporal hemianopia secondary to optic chiasmal injury.

Disseminated pneumocephalus secondary to an unusual facial trauma

Pneumocephalus can be secondary to a postintrathecal procedure, sinus fracture, basilar skull fracture, congenital skull defect, neoplasm, gas producing organism, barotrauma, neurosurgery, paranasal sinus surgery, mask or nasal continuous positive-airway pressure. Unusual facial traumas can also be rare causes of pneumocephalus. Here, we present such a case in whom an air compressor tip injury to both eyes led to the disseminated pneumocephalus. We report this rare case with the computed tomography findings and try to explain the possible mechanism of the pnemocephalus.

Pneumomediastinum revisited.

Pneumomediastinum may result from a variety of causes that may be either intrathoracic (eg, narrowed or plugged airway, straining against a closed glottis, blunt chest trauma, alveolar rupture) or extrathoracic (eg, sinus fracture, iatrogenic manipulation in dental extraction, perforation of a hollow viscus [corrected]. The radiographic signs of pneumomediastinum depend on the depiction of normal anatomic structures that are outlined by the air as it leaves the mediastinum. These signs include the thymic sail sign, "ring around the artery" sign, tubular artery sign, double bronchial wall sign, continuous diaphragm sign, and extrapleural sign. In distal esophageal rupture, air may migrate from the mediastinum into the pulmonary ligament. Pneumomediastinum may be difficult to differentiate from medial pneumothorax and pneumopericardium. Occasionally, normal anatomic structures (eg, major fissure, anterior junction line) may simulate air within the mediastinum. Iatrogenic entities that may simulate pneumomediastinum include helium in the balloon of an intraaortic assist device. In addition, pneumomediastinum may be simulated by the Mach band effect, which manifests as a region of lucency adjacent to structures with convex borders. The absence of an opaque line, which is typically seen in pneumomediastinum, can aid in differentiation. Computed tomographic (CT) digital radiography and conventional CT can also be helpful in establishing or confirming the diagnosis.

Early Combined Management of Frontal Sinus and Facial Fractures

Early Combined Management of Frontal Sinus and Facial Fractures