Management of the facial nerve following temporal bone ballistic injury.

Objective: To understand the patterns of temporal bone fracture and facial nerve injury from ballistic trauma. Study Design: Retrospective case series. Methods: Retrospective review of 42 patients evaluated following temporal bone ballistic injury at a single institution, university-based level-one trauma center between 2012 and 2021. Demographics, facial nerve status, CT images, interventions, complications, and outcomes were reviewed. Results: Mean age 30.3 years (range 5-58 years); 79% male. Racial demographics reflected the surrounding community. Seven mortalities occurred. Nineteen patients (54%) demonstrated facial nerve injury. Of those, 13/19 displayed immediate paralysis, 1 delayed, 5 unknown (due to altered mental status). On consultation, House-Brackmann grade 6 paralysis was common (13/19). Fracture was otic capsule-sparing in 17/19 (90%), universally comminuted, with significant disruption along the mastoid tip (16/19), external auditory canal (EAC) (15/19), and periauricular soft tissues (13/19). Nine patients underwent surgical intervention: Transmastoid facial nerve decompression to remove compressive bony spicules (n = 5); eye protection surgery (n = 3); and peripheral facial nerve exploration (n = 1), noting transection at the pes. One required middle cranial fossa and transmastoid repair of cerebrospinal fistulae in setting of severe meningitis. House-Brackmann scores improved in 80% following transmastoid nerve decompression despite CT evidence of likely additional injury in its extratemporal course. Conclusions: Common patterns of temporal bone fracture seen in blunt trauma (longitudinal/transverse, otic capsule-sparing/disrupting) were not found in patients with ballistic facial nerve injury. Rather, injury was commonly apparent in the EAC, mastoid tip, and periauricular soft tissues. Clinicians should have high suspicion for extratemporal facial nerve injury following ballistic trauma.

Management of Zygomaticomaxillary Complex Fractures.

Zygomaticomaxillary fractures account for approximately 25% of all facial fractures. They can be grouped into high-velocity and low-velocity injuries. A complete head and neck examination is critical for accurate clinical diagnosis. A thin-cut axial CT scan with sagittal, coronal, and 3-D reconstruction is important for accurate diagnosis and treatment planning. A thorough understanding of bony tetrapod anatomy and fracture mechanics is critical to treatment planning. Treatment options include closed and open reduction with internal fixation. Computer-aided applications can reduce the need for open reduction and improve the accuracy of both closed and open repairs.

Pediatric nasal surgery: timing and technique.

PURPOSE OF REVIEW: Timing of pediatric nasal surgery has always been a controversial topic. Concern over disrupting growing parts of the face and causing permanent facial deformity has led to a primarily conservative approach. Many surgeons feel that it is prudent to wait until the patient has completed nasal growth after puberty to pursue nasal surgery. RECENT FINDINGS: Recently, this attitude has been challenged with evidence that not only is nasal surgery in the pediatric age group not a detriment to facial growth, but failure to correct significant nasal deformity may actually cause dysmorphic facial growth secondary to obligate mouth breathing. Because of this, recent studies have focused on determining safe surgical techniques for pediatric nasal surgery, including inferior turbinate reduction, septoplasty and rhinoplasty. Research focus on this topic has also been expanded to include quality-of-life measures after nasal surgery. SUMMARY: Pediatric nasal surgery prior to puberty is not only safe, but may prevent facial deformity in certain patients.

Intermediate and Definitive Cleft Rhinoplasty.

Intermediate and definitive cleft rhinoplasties are a challenging part of definitive cleft care. The anatomy of the cleft nose is severely affected by the structural deficits associated with congenital orofacial clefting. A comprehensive understanding of the related anatomy is crucial for understanding how to improve the appearance and function in patients with secondary cleft nasal deformities. Timing of intermediate and definitive rhinoplasty should be carefully considered. A thorough understanding of advanced rhinoplasty techniques is an important part of providing adequate care for patients with these deformities.

Interventional sialendoscopy for treatment of juvenile recurrent parotitis.

OBJECTIVE: To evaluate our preliminary experience with interventional sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis (JRP). MATERIALS AND METHODS: Three consecutive pediatric patients with JRP who underwent interventional sialendoscopy were identified. Interventional sialendoscopy consisted of serial dilation of the Stenson's duct, endoscopy of the ductal system and saline irrigation followed by instillation of triamcinolone acetate. Clinical, demographic, procedure-related data and complications were documented. End points of the study were technical success, defined as completion of the procedure, subjective improvement in symptoms as indicated by the patients or their parents and assessment of safety in terms of complications. RESULTS: Three male patients with a mean age of 9 years (range 6-11 years) underwent interventional sialendoscopy for JRP. Endoscopic findings included a blanched stenotic duct with intraductal debris in those who were symptomatic. Technical success was 100%. The mean number of episodes of JRP in the year prior to presenting to our service among the three patients was 5 (range 4-6 per year). There were no new episodes of JRP reported at the last follow-up. There were no major complications. CONCLUSION: Our preliminary experience concurs with the current literature and suggests that interventional sialendoscopy is effective for the management of JRP and can be considered for patients who fail conservative medical management.

Retropharyngeal ganglioneuroma presenting with neck stiffness: report of a case and review of the literature.

OBJECTIVE: Ganglioneuromas rarely occur in the retropharynx with only three cases reported in the current literature. The most common symptom associated with retropharyngeal ganglioneuromas is dysphagia. We report a retropharyngeal ganglioneuroma with an unusual clinical presentation of neck stiffness and pain. STUDY DESIGN: Case report and review of literature. METHODS: A 42 year old woman presented with incapacitating neck pain and neck stiffness as well as dysphagia. Neurological work up was normal. Imaging revealed a hyper-dense, ill-defined, diffuse right retropharyngeal mass suggestive of a possible nerve sheath tumor with no communication with the cervical spine. Surgical removal was uneventful and associated with a post-operative Horner's syndrome. In follow-up, dysphagia and neck symptoms improved. CONCLUSION: Retropharyngeal ganglioneuromas can occur in a wide age range of patients. Surgical excision via a cervical approach offers definitive therapy but maybe associated with an iatrogenic Horner's syndrome for which the patients should be counseled prior to operative intervention. Neck pain is an atypical symptom that needs to be worked up to rule out a communication with the spinal column prior to surgical removal. Patients must be counseled that atypical symptoms may not completely resolve with surgical treatment.

Retropharyngeal ganglioneuroma presenting with neck stiffness: report of a case and review of literature.

Ganglioneuromas rarely occur in the retropharynx with only three cases reported in the current literature. The most common symptom associated with retropharyngeal ganglioneuromas is dysphagia. We report a retropharyngeal ganglioneuroma with an unusual clinical presentation of neck stiffness and pain. A 42-year-old woman presented with incapacitating neck pain, neck stiffness, right upper extremity weakness, as well as dysphagia. Neurological workup was normal. Imaging revealed a hyperdense, ill-defined, diffuse right retropharyngeal mass suggestive of a possible nerve sheath tumor with no communication with the cervical spine. Surgical removal was uneventful and associated with a postoperative Horner's syndrome. In follow-up, dysphagia and neck symptoms improved. Retropharyngeal ganglioneuromas can occur in a wide age range of patients. Surgical excision via a cervical approach offers definitive therapy but may be associated with an iatrogenic Horner's syndrome for which the patients should be counseled prior to operative intervention. Neck pain is an atypical symptom that needs to be worked up to rule out a communication with the spinal column prior to surgical removal. Patients must be counseled that atypical symptoms may not completely resolve with surgical treatment.