Nasal fractures: the taming of the shrewd

Objective/Hypothesis Closed reduction of nasal fractures has not been a satisfactory approach. Graduated protocols yield better results. Because a significant proportion of these closed reduction patients refuse a second operation, would it be better to resort to a full septorhinoplasty at the first operation and therefore decrease the post first operation deformity rate? Study Design Retrospective review of patients treated by the closed reduction technique and with a full septorhinoplasty approach. Methods Thirty‐four patients treated by the closed reduction technique were surveyed by telephone, and thus only patient satisfaction, which is usually higher in most studies, was allowed to influence the outcome. In another study, 52 patients treated with a full septorhinoplasty were reviewed by the surgeon. Results Sixty‐two percent of the closed reductions had esthetic or obstructive concerns. Of these with esthetic or obstructive concerns, 62% will not have a second operation for correction. Only 11.5% of those undergoing a full septorhinoplasty had esthetic concerns. Conclusion It may be necessary to adopt an early full septorhinoplasty approach in the initial treatment of nasal fractures to reduce the post first operation deformity/obstruction rates.     

Facial fractures and concomitant injuries in trauma patients

OBJECTIVES/HYPOTHESIS: Maxillofacial fractures often occur with serious concomitant injury in trauma patients, and knowledge of the type and severity of associated injuries can assist in rapid assessment and treatment. The objective was to identify the most commonly occurring injuries associated with facial fractures in severely injured trauma patients. STUDY DESIGN: Review of medical records. METHODS: A retrospective review was made of 151 patients with facial fractures presenting to a level-one trauma center over a 4-year span. All patients had an injury severity score of 12 or greater. Chart data recorded included demographics, etiology, presentation, facial fracture site, concomitant injury, imaging studies, hospital stay and course, interventions, and outcome. RESULTS: The most common cause or origin of facial fracture was assault (41%), followed by motor vehicle accident (26.5%). Orbital fracture was the most common overall facial fracture (24.2%), with nasal fractures being the most common isolated fracture (23.2%). Cerebral hematoma occurred in 43.7% of patients, with subdural hematoma being the most frequent. Pulmonary injury was the second most commonly associated injury (31.1%) with lung contusion being the most frequent. Seventy-two patients (42%) required intubation, and 22 (14.8%) required tracheostomy during their hospital stay. The hospital complication rate was 50.3% and included primarily pulmonary complications, septicemia, renal failure, and severe anemia. Thirteen patients died during their hospital stay; 11 of them died of neurologic injuries, 1 of pulmonary failure, and 1 of overwhelming sepsis. CONCLUSIONS: Cerebral and pulmonary injuries are often associated with maxillofacial fractures in severely injured trauma patients. Knowledge of these associated injuries provides useful strategies for patient care and prevention of further complications. A multidisciplinary and coordinated approach is important for optimum stabilization and ongoing treatment of patients with facial fractures.     

眶上颌颧骨复合骨折35例临床分析

目的：探讨眶上颌骨复合骨折复位固定的治疗效果。方法：开放性骨折患者行清创术同时予复位固定,闭合性骨折则应用发际切口及唇龈切口径路或两种径路并行复位固定。结果：３５例术后有２例咬合不定,１例面部畸形,２例张口受限,其余治疗效果满意。结论：熟悉局部解剖,及早复位,进行坚固内固定是治疗本病的关键。     

Treatment of zygomatic fractures: a follow-up study of 105 patients

One hundred and five patients with zygomatic fractures are presented. The main cause of the fracture was violence, followed by traffic accidents, fall and sport. In more than 25% of the cases, the fractures were accompanied by another fracture of the facial skeleton, viz maxillary, mandibular and nasal fractures. In severe cases of traffic accidents there were associated fractures in more than half of the cases. The follow-up study showed visible asymmetry of the face in 17 patients and sensory disturbances in 37 patients. We did not find the X-ray subdivision by Knight & North¹ useful in the evaluation of the stability of the fractures. As a method of choice in cases of dislocated zygomtic fractures, we used reposition by the method of Gillies and in cases of instability this reposition was combined with internal wiring, reconstruction of the orbital floor and antral packing. An active attitude towards reconstruction of the orbital floor is recommeded.     

Trends in blunt laryngotracheal trauma in children

Objective

To examine the presentation, mechanisms, and management of blunt laryngotracheal trauma in a pediatric population, emphasizing the rise in severity.

Design

Retrospective analysis of laryngotracheal trauma evaluated from 1995 to 2008. The presentation, mechanism, management and outcomes data are detailed.

Setting

Tertiary medical center.

Patients

Thirty-five patients were identified with major laryngotracheal trauma.

Main outcome measures

Surgical results, airway patency, voicing, swallowing and other residual disabilities are tabulated.

Results

Average age was 10.8 years, with boys outnumbering girls 22-13. In cases of major trauma, mechanisms were related to motor vehicle accidents (MVAs) in seven patients. Five of 11 major trauma victims were unconscious at presentation. Definitive airway reconstruction involved laryngotracheoplasty and tracheal resection/reanastomosis. Ten of 11 remain decannulated.

Conclusions

In an increasingly mobile society, major laryngotracheal trauma is occurring in a younger population. Victims of major laryngotracheal trauma may be unconscious or have other injuries that obscure airway injury, highlighting the need for vigilance. Once the airway is secured and the patient stabilized, airway reconstruction is undertaken, achieving decannulation in most patients. Hoarseness is often a lasting morbidity.     

Our 12 year experience with Montgomery T-tube in the management of acute blunt laryngotracheal trauma patients

IntroductionThe Montgomery T-tube is a device used as a combined tracheal stent and tracheostomy tube to prevent post-operative tracheal stenosis.ObjectivesThe purpose of this retrospective study is to evaluate the outcome following Montgomery T-tube stenting performed in for neck and airway injury in patients with acute blunt laryngotracheal trauma over a period of 12 years.MethodsBetween 2005 and 2017, 19 patients with acute blunt laryngotracheal trauma underwent Montgomery T-tube stenting. All 19 laryngotracheal trauma patients had undergone a preoperative tracheostomy in the emergency department by an ENT surgeon. Montgomery T-tube stenting was done later through an external approach. The follow up period ranged from 2 to 10 years. The Montgomery T-tube was removed after a period ranging from 6 months to 1½ year.ResultsThe majority of patients in the study were in the age group of 21–30 years. A preoperative tracheostomy was done in all 19 patients. All patients except 3 underwent successful decannulation, and experienced long-term satisfactory result.ConclusionManagement of acute blunt laryngotracheal trauma is a challenging problem that demands a multidisciplinary approach. The ideal treatment option should be individualized according to the patient's condition and characteristics of injury. According to our study we suggest that cases of acute blunt laryngotracheal trauma patients should be managed following the protocol as mentioned in our study, and we strongly emphasize that Montgomery T-tube should be left for at least 1 complete year in the airway as it results in negligible chances of post-traumatic stenosis of airway later.     

The efficacy of resorbable plates in head and neck reconstruction

OBJECTIVE/HYPOTHESIS: The advent of malleable macroporous resorbable plates has allowed the surgeon a greater range of reconstructive options and has decreased the morbidity of conventional plating procedures. Completely malleable after warming to 55 degrees C, resorbable plates can readily conform to most morphologic appearances of fractures or defects and provide rigid fixation when cooled. The plating systems used in head and neck reconstruction are described. STUDY DESIGN: Nine patients were selected for reconstruction using a resorbable plating system. The resorbable system was tested under a variety of clinical situations including frontal sinus fractures (three patients), midface fractures (two patients), mandibular defects (two patients), and laryngeal fractures (two patients). METHODS: Each case was evaluated for rigidity of fixation, and ease of plate contouring and application. Furthermore, the postoperative functional and cosmetic results and complications were contrasted between the resorbable plating systems and each surgeon's vast experience with traditional plating systems. RESULTS: The resorbable plating system was found to be as effective as traditional plating systems with respect to rigidity of fixation, functional results, and complications. In addition, the resorbable system was far easier to contour and, consequently, to apply, while producing higher cosmetic satisfaction after plate resorption than traditional plating. CONCLUSIONS: Based on our experience, resorbable plates appear to be safe, easy to contour and apply, as well as effective for a wide range of head and neck reconstructive applications. In addition, the shortcomings of permanently retained plates such as plate migration, bone growth restriction, and imaging artifact are avoided.     

Traumatic retropharyngeal hematoma: a rare and critical pathology needed for early diagnosis

Retropharyngeal hematoma occurs rarely. It is located just in front of the cervical spine. Many circumstances can lead to its development. A trauma and/or anticoagulants are often key factors. The assessment must be made extremely carefully as such a hematoma can induce an airway compromise. Trauma being a key factor, it can also present with cervical spine fractures, increasing the risks. Two different cases of retropharyngeal hematomas are reported. The first case required surgical management with tracheotomy, per-oral drainage and naso-gastric tube feeding. A total recovery was obtained in 2 weeks. The second patient underwent medical treatment (methylprednisolone), and recovery was obtained in 6 days. Surgery for retropharyngeal hematoma is not always mandatory. It becomes necessary when a major dysphagia or dyspnea occurs. In other cases, medical treatment and close observation are usually sufficient.     

闭合性喉外伤的诊治进展

闭合性喉外伤是一种具有隐匿性、复杂的、可危及生命的损伤,可遗留严重影响生活质量的并发症。由于其早期症状无特异性,且常合并其他部位的严重损伤,早期易被漏诊或误诊。在损伤的急性期,保证和维持气道的稳定是成功救治的基础。延迟识别和不恰当的干预均会影响患者预后,导致其正常的呼吸、吞咽及发声功能恢复困难。因此需依据详细询问病史和查体、结合内镜及影像学等检查结果,必要时行颈部探查术,对损伤进行全面、准确的评估,以指导个体化治疗策略的制定。为了提高闭合性喉外伤的早期识别率,并为诊治方案的选择、相关并发症的处理提供思路,现对近年来闭合性喉损伤诊治的相关文献进行综述,针对治疗难点,总结诊治方案。     

Astragaloside IV inhibits apoptotic cell death in the guinea pig cochlea exposed to impulse noise

X-ray microtomography (micro-CT) is a new technique allowing for visualization of the internal structure of opaque specimens with a quasi-histological quality. Among multiple potential applications, the use of this technique in otology is very promising. Micro-CT appears to be ideally suited for in vitro visualization of the inner ear tissues as well as for evaluation of the electrode damage and/or surgical insertion trauma during implantation of the cochlear implant electrodes. This technique can greatly aid in design and development of new cochlear implant electrodes and is applicable for temporal bone studies. The main advantage of micro-CT is the practically artefact-free preparation of the samples and the possibility of evaluation of the interesting parameters along the whole insertion depth of the electrode. This paper presents the results of the first application of micro-CT for visualization of the inner ear structures in human temporal bones and for evaluation of the surgical positioning of the cochlear implant electrodes relative to the intracochlear soft tissues.