Olfactory and Gustatory Function in Patients With Different Types of Maxillofacial Trauma.

OBJECTIVES/HYPOTHESIS: To investigate olfactory and gustatory function in patients with maxillofacial trauma and associated fractures. STUDY DESIGN: Retrospective cohort study. METHODS: Olfactory and gustatory function was assessed psychophysically in 124 patients who had sustained maxillofacial trauma with an associated fracture. Five groups were defined based on the fracture type: Le Fort, mandibular, nasal, orbital, and zygomatic. Olfaction was measured with Sniffin' Sticks (threshold, discrimination, identification [TDI] score) and gustation with the taste spray method. Patients self-rated olfactory and gustatory function on a visual analog scale prior to formal testing. RESULTS: Ten out of 124 patients were found to be anosmic (8%), with half of them found in the Le Fort (skull base) group. The Le Fort fracture group had significantly lower olfactory function than other fracture types (TDI score = 22.4 ± 10.7; P = .01; possible range = 1-48). The mean gustatory spray test score was 3.82 ± 0.4 (possible range = 0-4) without any intergroup differences. Self-rated olfactory function showed a correlation with the measured scores (r = 0.61, P < .001) across all groups. CONCLUSIONS: The present data show a significant effect of maxillofacial fracture type on the development of anosmia. Maxillofacial fractures involving the skull base, such as Le Fort fractures, are more likely to cause permanent smell loss, whereas the other fracture types are rarely associated with anosmia. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E331-E337, 2021.

How accurate is the treatment of midfacial fractures by a specific navigation system integrating "mirroring" computational planning? Beyond mere average difference analysis.

PURPOSE: To evaluate the accuracy of a specific navigation system integrating "mirroring" computational planning in the treatment of midfacial fractures by comparing planned with actual postoperative 3-dimensional (3D) images. PATIENTS AND METHODS: Preoperative planned and postoperative 3D computed tomographic (CT) and cone-beam CT (CBCT) images of 20 patients with midfacial fractures were analyzed. Images were fused using dedicated software (iPlan Cranial 2.6). They were imported in Standard Tessellation Language (STL) format to open-source software (Meshlab) and resized to delineate the surgically repositioned portion of bone. The images were imported in STL format to ad hoc software for calculating the surface differences between the 2 3D images. The distribution of the differences was assessed using boxplots for each patient, and the proportion of the actual image close to the planned image was estimated by the proportion of values within an accuracy cutoff set at ±2 mm. RESULTS: The mean difference between the 2 3D surfaces was 0.12 mm. The proportion of values between the 2 surfaces and included within the interval of accuracy was greater than 90% in 6 patients (30%), 80 to 90% in 6 patients (30%), 50 to 80% in 7 patients (35%), and less than 50% in 1 patient (5%). CONCLUSION: This study showed that post-traumatic midfacial reconstruction can be accurately approximated and thus predicted by a specific navigation system integrating "mirroring" computational planning for most patients. Further study should examine risk factors for inaccurate prediction.

Accuracy of computational soft tissue predictions in orthognathic surgery from three-dimensional photographs 6 months after completion of surgery: a preliminary study of 13 patients.

BACKGROUND: This study aimed at a preliminary evaluation of the accuracy of computed three-dimensional (3D) predictions in orthognathic surgery by comparing predicted and real postoperative results. METHODS: Pre- and postoperative 3D photographs and time-matching computed tomography (CT) and cone-beam CT scans of the face of 13 patients with dentofacial deformities were analyzed. Three-dimensional photographs were fused with preoperative CT data using dedicated software (3dMDvultus, version 2.2.0.8). Postoperative CT data were superposed on the preoperative skull. With an activated rendering function, the osteotomies were simulated in the preoperative CT data and the bony segments moved to their real postoperative position, resulting in a textured soft tissue prediction. This computed skin surface was compared with the real postoperative result by dividing the face into a surgically treated lower half and an untreated upper half. A statistical quantitative analysis of the surfaces was performed. RESULTS: The mean differences between surfaces were +0.27 mm for the untreated upper half and -0.64 mm for the surgically treated lower half (p < 0.001). Averaged distributions of absolute errors showed more discrepancies between predicted and real postoperative results in the lower half of the face. Errors exceeding 3 mm were encountered in 4 % of the upper halves versus 29.8 % of the lower halves (p < 0.001). CONCLUSIONS: The accuracy of a specific software platform for predicting 3D soft tissue changes after surgery was insufficient. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Deep neck space abscesses of dental origin: the impact of Streptococcus group Milleri.

In recent years, there has been rising interest in Streptococcus group Milleri (SM) because high mortality rates have been related to it. In case of deep neck infections (DNI), whatever the origin, mortality rates as high as 26% were reported. But there are no data available for DNI with SM of purely dental origin. The aim of our article was to describe and analyse DNI of purely dental origin involving on one hand SM and on the other hand infections without presence of SM. We compared these two groups and statistically investigated if there were differences in clinical presentation (age, mouth opening, length of hospital stay, laboratory parameters) or clinical behaviour (re-operation, re-hospitalisation, secondary osteomyelitis, stay at intensive care, length of antibiotic treatment, presence of resistances against antibiotics, incapacity to work). For this, we retrospectively searched medical records of our institution for all purulent DNI treated from 2004 till 2012. We found 81 patients meeting all inclusion criteria. Thirty-four patients had involvement of SM, 47 did not. The only statistically significant difference between the SM group and the non-SM group was the length of incapacity to work. All other parameters were non-significant. Furthermore, there were no fatalities. In conclusion, the clinical importance of this article is that patients with deep neck abscesses of purely dental origin involving SM do not need more or different care when compared to all other DNI of dental origin.

Can systematic computed tomographic scan assessment predict treatment decision in pure orbital floor blowout fractures?

PURPOSE: To describe and evaluate the reliability and the accuracy of a specific computed tomography-based assessment in predicting treatment decisions for pure orbital floor blowout fractures (BOFs). MATERIALS AND METHODS: In this retrospective cohort study, the charts of all patients presenting with isolated BOFs from January 2009 through April 2011 at the University Hospital of Geneva were reviewed. The systematic computed tomographic assessment included the following 3 parameters: 1) ratio of the fractured orbital floor; 2) maximal height of periorbital tissue herniation, and 3) a 4-grade muscular subscore describing the position of the inferior rectus muscle relative to the level of the orbital floor. The parameters' predictive value regarding the treatment decision (conservative vs surgical) was assessed by logistic regression and relative operating characteristic curves. RESULTS: Forty-eight patients (24 male) were included. The patients' mean age was 49.5 years. The ratio of the fractured orbital floor, the maximal height of periorbital tissue herniation, and the muscular subscore were significant predictors in univariate analysis (P = .02, P = .006, P = .001, respectively), whereas, in a multivariate analysis, only muscular subscore remained a significant predictor (P = .003) and reached a similar predictive ability as the 3 parameters together. CONCLUSIONS: The present study showed that the severity of inferior rectus muscle displacement is the most important independent predictive radiologic factor in the treatment decision-making process for pure BOFs. This systematic computed tomographic assessment is a valuable tool for a better understanding of BOF management overall. Further studies are needed to establish its clinical relevance.

Severe subcutaneous and deep cervicofacial emphysema of unusual etiology.

Subcutaneous and deep cervical emphysema (SCE) in the head and neck are found in a wide spectrum of conditions. Most of them are seen in patients with midfacial trauma or oropharyngeal infections. Subcutaneous and deep cervical emphysema can also be a symptom of life-threatening mediastinitis and/or necrotizing fasciitis, both of which need immediate surgery. Rarely however does SCE occur in isolation as a consequence of elevated intraoral pressure in combination with or without visible lacerations of the oral mucosa. As a consequence, air penetrates the mucosal tears and results in subcutaneous emphysema even extending down to the mediastinum in severe cases. This article describes a series of five cases of isolated SCE. It discusses the diagnosis, the pathomechanism, the differential diagnosis and the treatment. It underlines the importance of anamnesis and careful physical and laboratory examinations in order to differentiate isolated SCE from more severe conditions such as necrotizing fasciitis or mediastinitis, which necessitate immediate surgery.

A quick guide to positioning the transbuccal set.

Exact positioning of the transbuccal set can be tricky, especially under aggravating circumstances as present scarring or high body mass index. It may result in multiple skin incisions. This article presents a simple and fast guidance technique that can help in the exact positioning of skin incision and transbuccal set.

Image guided surgical navigation integrating "mirroring" computational planning based on intra-operative cone-beam CT imaging: a promising new approach for management of primary bilateral midfacial fractures.

Cosmetic and functional re-establishment following primary or secondary treatment of comminuted and complex midfacial fractures remains a challenge for surgeons. Computer Assisted Surgery (CAS) has revolutionized the conceptualization and approach to these reconstructions and has become a reliable part of the surgical armamentarium. Computer aided design/modeling (CAD/CAM) software that allows "mirroring" planning coupled to navigation systems has dramatically improved surgical strategies in reconstructive surgery of the craniomaxillofacial skeleton, particularly with respect to the prediction of suitable symmetric bone repositioning. So far, however, use of this approach has been limited to unilateral cases, with a non-fractured contralateral side being considered the condition sine qua non for the application of such a technique and the "mirroring" planning being performed on pre-operative CT imaging. We report a case of complex primary reconstruction in a patient presenting with bilateral midfacial fractures, using complete intra-operative sequence processing with a navigation system integrating "mirroring" computational planning based on a mobile C-arm cone-beam computed tomography (CBCT) scan with a flat-panel detector. To the best of our knowledge, no similar cases have yet been reported involving the use of this sequencing method in the primary management of bilateral midfacial fracture reconstruction.

Gustatory dysfunction after mandibular zoster.

Varicella zoster, limited to the mandibular nerve, is rare. Classical symptoms are pain, hypesthesia and vesicular eruption restricted to the third trigeminal segment (V3). Little is known on taste affection after mandibular nerve zoster. We report two cases of patients suffering from mandibular zoster associated with subjective taste disorder. In both cases, gustatory measures confirmed ipsilateral hemiageusia of the anterior two-thirds of the tongue. After 2 months, the symptoms regressed and psychophysical measures came back to normal values, whereas post-zoster neuralgia lasted for more than 1 year. Gustatory dysfunction is a possible symptom after mandibular nerve zoster. In contrast to post-zoster neuralgia, taste function seems to recover quickly.

Accuracy and predictability in use of AO three-dimensionally preformed titanium mesh plates for posttraumatic orbital reconstruction: a pilot study.

The aim of this study was to prospectively evaluate the accuracy and predictability of new three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction.We analyzed the preoperative and postoperative clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. Fracture locations were as follows: floor (N = 7; 70%), medial wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor fractures were exposed by a standard transconjunctival approach, whereas a combined transcaruncular transconjunctival approach was used in patients with medial wall fractures. A three-dimensional preformed AO titanium mesh plate (0.4 mm in thickness) was selected according to the size of the defect previously measured on the preoperative computed tomographic (CT) scan examination and fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of plate positioning of the reconstructed orbit was assessed on the postoperative CT scan. Coronal CT scan slices were used to measure bony orbital volume using OsiriX Medical Image software. Reconstructed versus uninjured orbital volume were statistically correlated.Nine patients (90%) had a successful treatment outcome without complications. One patient (10%) developed a mechanical limitation of upward gaze with a resulting handicapping diplopia requiring hardware removal. Postoperative orbital CT scan showed an anatomic three-dimensional placement of the orbital mesh plates in all of the patients. Volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 2.5 cm(3). There was no significant difference in volume between the reconstructed and uninjured orbits.This preliminary study has demonstrated that three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction results in (1) a high rate of success with an acceptable rate of major clinical complications (10%) and (2) an anatomic restoration of the bony orbital contour and volume that closely approximates that of the contralateral uninjured orbit.

Prognostic factors for the malignant triton tumor of the head and neck.

BACKGROUND: Malignant triton tumors are rare neoplasias consisting of a malignant peripheral nerve sheath tumor with additional rhabdomyoblastic differentiation. These tumors are highly aggressive and prognosis is poor. Our aim is to describe the outcome and to identify potential prognostic factors. METHODS: From 1993 to 2005, 7 patients with a malignant triton tumor of the head and neck were treated at our institution. A literature search revealed another 46 published cases. All these cases were analyzed for outcome and prognostic factors. RESULTS: Patients with primary tumors involving the nose and paranasal sinuses have better, patients involving the neck a poor prognosis. All other locations show an intermediate course. Complete surgical removal is of crucial importance. Additional radiation or chemotherapy show little effect. CONCLUSION: Location of the primary tumor is a key factor for prognosis. Complete surgical removal is the only treatment associated with survival.

Magnesium sulfate in the management of patients with aneurysmal subarachnoid hemorrhage: a randomized, placebo-controlled, dose-adapted trial.

BACKGROUND: Recent studies suggest that high-dose MgSO4 therapy is safe and reduces the incidence of DIND and subsequent poor outcome after SAH. We intended to assess the safety and efficacy of high-dose MgSO4 therapy after SAH as means to prevent DIND and to evaluate the impact on clinical outcome. METHODS: This was a prospective, randomized, single-blind, placebo-controlled study. The MgSO4 infusion was adjusted every 12 hours until day 12 according to the target serum Mg2+ level. The occurrence of DIND, secondary infarction, side effects, and the outcome after 3 and 12 months were assessed. RESULTS: Fifty-eight patients were randomized; 27 received placebo and 31 MgSO4. The difference in occurrence of DIND and secondary infarction was not significant. The intention-to-treat analysis revealed a trend toward better outcome (P = .083) after 3 months. On-treatment analysis showed a significantly better outcome after 3 months (P = .017) and a trend toward better outcome after 1 year (P = .083). Significantly more often hypotension (P = .040) and hypocalcemia (P = .005) occurred as side effects in the treatment group. In 16 patients (52%), the MgSO4 therapy had to be stopped before day 12 because of side effects. No predictive factor leading to termination was found in a postrandomization analysis. CONCLUSIONS: High-dose MgSO4 therapy might be efficient as a prophylactic adjacent therapy after SAH to reduce the risk for poor outcome. Nevertheless, because of the high frequency of the side effects, patients should be observed in an intensive or intermediate care setting.

[Wide-spread subcutaneous emphysema after third molar extraction. Case report]. / Ausgedehntes subkutanes Emphysem nach Weisheitszahnentfernung. Ein Fallbericht.

Two days after wisdom teeth removal an eighteen-year-old man complained of a painful subcutaneous neck emphysema. CT scans showed that the air collections were expanding close to the mediastinum. A conservative intravenous medication with broadspectrum antibiotics was administered and within three days the symptoms resolved completely without any surgical intervention. Subcutaneous emphysema after dental treatment can develop into infectious, potentially lethal fasciitis and mediastinitis. Therefore it must be thoroughly examined and immediately operated on, if suspicious of an infection.