Management of frontal sinus fractures: a review of 33 cases.

PURPOSE: The purpose of this article is to provide an overview of fracture patterns, patient characteristics, and surgical approaches associated with frontal sinus fractures. The short- and long-term complications of frontal sinus fractures treated over a 20-year period are presented. PATIENTS AND METHODS: The records of patients admitted to the University of Kentucky Medical Center from 1975 through 1994 with a diagnosis of frontal sinus fracture were reviewed. Fracture patterns were categorized and information collected related to demographics, circumstance of injury, perioperative management, surgical procedures, and complications. Long-term complications were studied by asking patients to return for clinical and radiographic follow-up. RESULTS: The average age of patients with frontal sinus fractures was 32 years. Thirty-one of the 33 victims were male. Motor vehicle accidents were the most common cause. Twenty-one patients had anterior table fractures (type I), 11 had combined anterior/posterior table fractures (type II = 9, type IV = 2), and one patient had an isolated posterior table fracture (type III). Short-term postoperative and perioperative complications were minimal. Long-term complications included acute frontal sinusitis (one patient), cosmetic forehead defects (two patients), and encephalitis (one patient). CONCLUSIONS: The critical elements to successful frontal sinus fracture repair are precise diagnosis of the craniofacial fracture pattern, appropriate management of the frontonasal duct(s), and prevention of serious brain sequelae. Long-term follow-up of patients with frontal sinus injuries is recommended.

A preliminary study of reconstruction of the monkey temporomandibular joint with autogenous tissues.

PURPOSE: This study investigated the ability of autogenous pericranium-muscle and cranial bone to restore form and function of the temporomandibular joint (TMJ). MATERIALS AND METHODS: A right TMJ discectomy, condylectomy, vertical ramus osteotomy with superior repositioning of the proximal fragment, and a cranial bone graft to the mandibular angle were performed in 12 cynomolgus monkeys. Clinical, histologic, and autoradiographic evaluation was done at intervals beginning at 3 days and continuing up to 78 weeks. RESULTS: No significant postoperative sequela were identified in any of the monkeys. Jaw mobility and function were restored. Gross morphologic condylar changes were observed. The pericranium-muscle grafts did not differentiate into normal disc-like structures and a cartilage cap did not cover the condyle stump head. CONCLUSIONS: The results of this study suggest that the previous TMJ function was restored. However, the histologic changes observed were consistent with advanced degenerative joint disease.

Principles of management of complex craniofacial trauma.

Successful treatment of patients with complex craniofacial injuries is heavily dependent on the surgeon's appreciation of the associated nonfacial injuries, precise clinical and diagnostic imaging examinations to establish a three-dimensional configuration of the fractured segments, and the application of well-established principles of facial fracture repair. Factors that influence improved treatment outcome are 1) early definitive treatment, 2) anatomic and functional repair of naso-orbito-ethmoidal injuries, 3) wide exposure of fracture segments, and 4) anatomic repositioning and stable fixation of fracture segments in all planes of space.

Chondromyxoid fibroma of the maxilla. Electron microscopic findings and review of the literature.

A case of chondromyxoid fibroma of the anterior maxilla is presented. The light and electron microscopic appearances of this tumor are described. A review of chondromyxoid fibromas of the jaws is performed, with a discussion of the appropriate therapy.

Nasal endotracheal intubation for outpatient anesthesia.

A review of the literature disclosed many potential complications associated with endotracheal anesthesia. A retrospective review of the records of the general anesthetics administered to 5,223 outpatients receiving nasal endotracheal intubation at the Ohio State University was undertaken. This review showed minimal serious complications associated with nasal endotracheal anesthesia used for outpatients.

Monitoring microvascular reactivity in dental subjects.

In this section of a larger study, a system for monitoring changes in the microcirculation, in humans in the dental setting, is described. The technique involves clinical nailfold capillary photomicroscopy and electronic image-scan measurements. The system was tested using reactive hyperemia after vascular occlusion; it proved reliable and sufficiently sensitive for measuring vascular reactivity in humans. (In a subsequent paper, clinical findings relative to the use of this technique with patients undergoing nitrous oxide/oxygen anesthesia will be presented).The importance of the microcirculation for the integrity of the tissues cannot be overemphasized. Since the term "microcirculation" can be defined as the microscopic subdivisions of the vascular system that lie within the tissue proper and are exposed to its immediate environment,(1) it is evident that most of the exchange of nutrients and waste products occuring in the tissue will occur at this level. Furthermore, the adequacy of tissue perfusion during drug administration, or during and after anesthesia, is dependent on the adequacy and reactivity of this subdivision of the vascular system.(2)A basic prerequisite to the understanding of microcirculatory function in a given vascular bed is the precise quantitation of dimensional changes in those vessels(3). Dynamic measurements in vivo are required, since it is difficult, if not impossible, to ensure that the dimensions obtained from fixed tissue specimens are accurate measures of those occurring in the living state. This is especially true where vessel dimensions are rapidly changing in response to endogenous or exogenous influences. Unfortunately the task of in vivo measurement of microvascular dimensions is difficult in most microcirculatory beds. Since the vessels are an integral part of a threedimensional structure,(4) the tasks of visualizing, isolating and measuring the vessels are formidable. These difficulties are compounded if the particular vessels to be studied are in human subjects where surgical intervention is unacceptable. For these reasons, previous studies of dimensional changes in the microcirculation, involving a variety of techniques (still photography, cinematography, television microscopy,(5) image-scanning,(6) image-shearing(7,8) and optical density measurements(9)), were almost always carried out in animals.In order to determine the effects of drugs and anesthetic gases on the peripheral microcirculation in human subjects undergoing dental treatment, we have employed a non-invasive photomicrographic method to measure planar dimensional changes in human nailfold capillaries. In this report we will describe this technique, its use in measuring microcirculatory changes in humans in a dental setting, and the results of a study undertaken to determine if it is sensitive enough to measure an induced change in vascular dimensions.

Monitoring Microvascular Reactivity: (II) - Short-Term Effect of Nitrous-Oxide on the Peripheral Microcirculation in Humans.

A study was carried out to monitor directly the short-term effects of N(2)O/O(2) inhalation-sedation on the peripheral microcirculation in healthy human subjects in a simulated dental setting. The inhalation of 40% N(2)O and 60% O(2) led to a small but significant mean percent decrease (-6.89 +/- 1.2 SEM) in relative vessel diameter in the nailfold capillaries, for the entire N(2)O-breathing period. Individual vessels showed a marked constriction (-31.7% +/- 4.4 SEM, mean maximal decrease); the time to this maximum constriction varied with the individual vessels. This constriction could not be attributed to changes in oxygen or carbon dioxide levels in the alveolar gas, or to changes in heart rate, systolic blood pressure, respiratory rate or temperature. Further studies are indicated to determine whether this effect is sustained with long term administration, and whether it is clinically significant, especially in those patients with acquired cardiac disease or those taking vasoactive drugs.

Cancellous bone marrow grafts in irradiated dog and monkey mandibles.

A pilot study was conducted to investigate the osteogenic potential of autogenous cancellous marrow grafts placed in irradiated tissue. Five dogs and three monkeys received either 4,100 or 6,520 rads of cobalt-60 irradiation during a 5- or 8-week period. Postirradiation discontinuity mandibular defects were created surgically and restored with autogenous cancellous bone marrow grafts held in position by a titanium mesh basket. Bony union occurred in all the mandibles. Intraoral ulceration was common in the dogs, and extraoral wound dehiscence was found in the monkeys. Hematopoietic marrow was present in the graft sites of both species 6 months to 1 year after surgery.

Autogenous cancellous-marrow bone grafts in irradiated dog mandibles.

A pilot study was conducted to investigate the osteogenic potential of autogenous cancellous-marrow grafts placed in irradiated tissue. Three dogs received 4,100 rads in ten treatments ooer 32 days. Postirradiation discontinuity mandibular defects were created. These defects were restored with cancellous-marrow autogenous bone supported in position by a titanium mesh basket. Bony union occurred in all the mandibles. The titanium mesh partially eroded through the oral mucosa in two animals. The quantity of new bone formed in the surgical defect varied. Two dogs had complete restoration of the resected mandible. Histologic observations were documented in both the graft area and the surgically uninvolved contralateral side of the mandible.

Aspergillosis of the maxillary sinus. Review of the literature and report of a case.

Aspergillosis of the paranasal sinuses is an infrequently reported disease which can occur in two forms: (1) a noninvasive form that can clinically mimic nonspecific chronic sinusitis and (2) an invasive form that can simulate malignant disease of the sinuses. The disease occurs without known predisposing systemic disease. Primary treatment consists of surgical eradication of infected tissue. The question of whether concomitant antifungal chemotherapy should be used in the noninvasive form of aspergillosis has not been definitely resolved. Presented is a review of the literature, the report of a case, and a discussion of possible pathogenic mechanisms.