Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches.

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

Current Management of Subcondylar Fractures of the Mandible, Including Endoscopic Repair.

Treatment of subcondylar fractures has been the subject of debate for many years. Options for treatment include physical therapy, elastic maxillomandibular fixation, and open repair. Proper imaging and clinical evaluation are imperative when deciding on the best management option. In the past, most subcondylar fractures were treated with a closed approach. Recent data support open repair, when feasible. Studies show increased interincisal opening, lateral excursion, and protrusion with less mandibular shortening, jaw deviation, and pain. There are serious side effects that may be associated with open repair. The surgical technique for endoscopic repair is outlined in detail.

Controversies in the Management of the Trauma Patient.

Facial trauma is a significant cause of morbidity in the United States. Despite the large volume of trauma surgeries at most academic institutions, there is still controversy regarding management of many traumatic injuries. The literature lacks clear-cut best practices for most fractures. In orbital trauma, there is debate about the optimal timing of repair, preferred biomaterial to be used, and the utility of evaluation afterward with intraoperative computed tomographic scan. In repair of mandible fractures, there is debate regarding open versus closed reduction of subcondylar fractures, or alternatively, endoscopic repair.

Decade review of mandible fractures and arch bar impact on outcomes of nonsubcondylar fractures.

OBJECTIVES/HYPOTHESIS: Review trends in mandible fracture management and outcomes in patients treated with and without intraoperative arch bar use. STUDY DESIGN: Retrospective chart review. METHODS: All patients with mandible fractures between October 1, 2001, and October 1, 2011, were reviewed. Excluded were those with concomitant midfacial fractures or inadequate follow-up. RESULTS: Overall, 734 patients sustained 1,312 mandible fractures. Assault was the most common etiology. The parasymphyseal, subcondylar, and angle regions were most likely fractured. In total, 85% of patients underwent open-reduction internal-fixation (ORIF). This overall number had no significant annual deviation. However, use of arch bars to achieve intraoperative maxillomandibular fixation (MMF) with ORIF decreased annually, whereas the use of manual reduction with ORIF increased annually. These trends held statistical significance. Outcomes were reviewed in patients with one or two nonsubcondylar fractures by assessing complications of malocclusion, infection, and malunion. In 228 patients meeting criteria, the incidence of complications was 12.9% in those treated using intraoperative arch bars with ORIF and 12.5% in those using manual reduction with ORIF. When assessing individual complications, there was no statistically significant difference. CONCLUSION: Our data suggest a shifting trend in mandible fracture management. Our techniques for achieving fracture reduction ideal for ORIF favors manual reduction over the use of arch bars in select cases. We found no statistical increase in the incidence of complications when using manual reduction with ORIF in patients with one and two nonsubcondylar fractures. In appropriately selected cases, manual stabilization of fractured segments is an alternative to using arch bars to achieve intraoperative MMF. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:596-601, 2016.

Incidence of Concussion in Patients With Isolated Mandible Fractures.

IMPORTANCE: This study examines the association between isolated mandible fractures and mild traumatic brain injury (mTBI). OBJECTIVE: To determine the rates of mTBI in patients who have sustained isolated mandible fractures. DESIGN, SETTING, AND PARTICIPANTS: A prospective study was conducted among patients who sustained isolated mandible fractures within 24 hours of presentation. Patients were administered the Military Acute Concussion Evaluation (MACE). Recorded data included demographics, time since injury, use of alcohol or illicit drugs, nonfacial pain, and mechanism of injury. All patients were evaluated in the emergency department of a level I trauma center between June 20, 2013, and June 20, 2014. In addition, discharge data from the Nationwide Inpatient Sample database was analyzed to identify current rates of patients with a diagnosis of both mandible fractures and concussions. MAIN OUTCOMES AND MEASURES: Rates of concussion. Patients with a MACE score of less than 25 were considered to have mTBI. RESULTS: Sixteen patients met the study criteria over a 1-year period. Fourteen patients (88%) were male, and mean age was 27.5 years. The mean time since injury was 11.25 hours (range, 3-21 hours). The mechanism of injury was assault in 12 patients (75%), sports in 2 patients (13%), all-terrain vehicle crash in 1 patient (6%), and biking in 1 patient (6%). Eight patients (50%) admitted to the use of alcohol, and none reported the use of illicit drugs. Eleven patients (69%) reported loss of consciousness. Twelve patients (75%) met criteria for concussion according to the MACE. Among these 12 patients, 7 (58%) admitted to the use of alcohol at the time of injury. There was no relationship between the rates of concussion and the use of alcohol. CONCLUSIONS AND RELEVANCE: Mandible fractures are often sustained after high-force impacts during altercations between men. In our study, a 75% (12 of 16) rate of concussions associated with isolated mandible fractures was identified. Patients with isolated mandible fractures may benefit from being screened for concussion and referred to a concussion clinic. LEVEL OF EVIDENCE: 4.

Radiation-induced epithelial-myoepithelial carcinoma in a patient previously treated with mantle-field radiation therapy for Hodgkin lymphoma.

BACKGROUND: Radiation-induced salivary gland tumors are well described in the literature, with mucoepidermoid cancer being the most common histologic entity. Epithelial-myoepithelial carcinoma is a rare tumor accounting for <1% of all tumors in the salivary glands. METHODS AND RESULTS: We describe the first case of radiation-induced epithelial-myoepithelial carcinoma in the English-language medical literature. A 48-year-old man presented with right-sided mandibular pain and trismus, 25 years after mantle-field radiation therapy (RT) for Hodgkin lymphoma. He underwent excision of a right submandibular mass, which revealed a diagnosis of epithelial-myoepithelial carcinoma. Although typically a low-grade tumor, the histology revealed extensive necrosis and high mitotic activity. The patient required multiple resections and adjuvant therapy after multiple recurrences over a 4-year period. CONCLUSION: Reports of epithelial-myoepithelial carcinoma are relatively rare and this case highlights the importance of long-term follow-up and increased awareness of the risks of salivary gland tumors in this population.

Pediatric craniomaxillofacial trauma.

Trauma is a leading cause of death in children. The pediatric facial skeleton goes through progressive development and major changes, including change in the size ratio of the cranium to the face; change in the ratio of facial soft tissue to bone, and pneumatization of the sinuses. The main goal of maxillofacial fracture repair is to reestablish normal or preinjury structure and function. Follow-up is typically recommended until children reach skeletal maturity as trauma may affect growth of the facial skeleton. Problems not obvious immediately after the injury may become an issue later, and secondary surgery might be needed to address such issues.

The Comprehensive AOCMF Classification: Skull Base and Cranial Vault Fractures - Level 2 and 3 Tutorial.

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial classification system with increasing level of complexity and details. The highest level 1 system distinguish four major anatomical units, including the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). This tutorial presents the level 2 and more detailed level 3 systems for the skull base and cranial vault units. The level 2 system describes fracture location outlining the topographic boundaries of the anatomic regions, considering in particular the endocranial and exocranial skull base surfaces. The endocranial skull base is divided into nine regions; a central skull base adjoining a left and right side are divided into the anterior, middle, and posterior skull base. The exocranial skull base surface and cranial vault are divided in regions defined by the names of the bones involved: frontal, parietal, temporal, sphenoid, and occipital bones. The level 3 system allows assessing fracture morphology described by the presence of fracture fragmentation, displacement, and bone loss. A documentation of associated intracranial diagnostic features is proposed. This tutorial is organized in a sequence of sections dealing with the description of the classification system with illustrations of the topographical skull base and cranial vault regions along with rules for fracture location and coding, a series of case examples with clinical imaging and a general discussion on the design of this classification.

The Comprehensive AOCMF Classification System: Fracture Case Collection, Diagnostic Imaging Work Up, AOCOIAC Iconography and Coding.

The AO classification system for fractures in the adult craniomaxillofacial (CMF) skeleton is organized in anatomic modules in a 3 precision-level hierarchy with account for an increasing complexity and details. Level-1 is most elementary and identifies no more than the presence of fractures in 4 separate anatomical units: the mandible (code 91), midface (92), skull base (93) and cranial vault (94). Level-2 relates the detailed topographic location of the fractures within defined regions of the mandible, central and lateral midface, internal orbit, endo- and exocranial skull base, and the cranial vault. Level-3 is based on an even more refined topographic assessment and focuses on the morphology - fragmentation, displacement, and bone defects - within specified subregions. An electronic fracture case collection complements the preceding tutorial papers, which explain the features and options of the AOCMF classification system in this issue of the Journal. The electronic case collection demonstrates a range of representative osseous CMF injuries on the basis of diagnostic images, narrative descriptions of the fracture diagnosis and their classification using the icons for illustration and coding of a dedicated software AOCOIAC (AO Comprehensive Injury Automatic Classifier). Ninety four case examples are listed in two tables for a fast overview of the electronic content. Each case can serve as a guide to getting started with the new AOCMF classification system using AOCOIAC software and to employ it in the own clinical practice.

Complications in facial trauma.

This article reviews common complications encountered in the setting of facial trauma. Many complications are the result of the primary injury, and a facial plastic surgeon should be able to quickly identify these to prevent further morbidity. Common pitfalls and controversial topics are presented, as well as an overview of treatment for many complications.

Recent advances in fixation of the craniomaxillofacial skeleton.

PURPOSE OF REVIEW: Fixation of the craniomaxillofacial skeleton is an evolving aspect for facial plastic, oral and maxillofacial, and plastic surgery. This review looks at the recent advances that aid in reduction and fixation of the craniomaxillofacial skeleton. RECENT FINDINGS: More surgeons are using resorbable plates for craniomaxillofacial fixation. A single miniplate on the inferior border of the mandible may be sufficient to reduce and fixate an angle fracture. Percutaneous K-wires may assist in plating angle fractures. Intraoperative computed tomography (CT) may prove to be useful for assessing reduction and fixation. SUMMARY: Resorbable plates are becoming increasingly popular in orthognathic surgery and facial trauma surgery. There are newer operative techniques for fixating the angle of the mandible. Also, the utilization of the intraoperative CT provides immediate feedback for accurate reduction and fixation. Prebent surgical plates save operative time, decrease errors, and provide more accurate fixation.

Osteochondroma of the coronoid process (Jacob's disease): an unusual cause of restricted jaw motion.

Osteochondromas are the most common benign bone tumor, most commonly found in the ends of long bones; however, they rarely involve facial bones, particularly the mandible. Osteochondromas involving the coronoid process have rarely been reported in the literature but pose a diagnostic dilemma. When large enough, osteochondromas of the mandibular coronoid process can form a joint with the zygomatic arch (Jacob's disease). This pseudoarticulation results in restricted jaw motion, which can clinically be mistaken for temporomandibular joint dysfunction. We report a case of a 39-year-old man with chronic restricted jaw motion undiagnosed for several years.

Otologic considerations of blast injury.

The ear by design is exquisitely sensitive to barotrauma. As a result, it is typically the first organ affected in primary blast injury. The most common symptoms encountered include hearing loss, ringing, and drainage. In severe cases, the highest priority is appropriately directed toward diagnosis and treatment of life-threatening injuries; however, injury to the ear is missed frequently. With simple screening procedures, limited management, and appropriate otolaryngologic referral, acute and long-term morbidity can be averted for both critical and noncritical patients. The article provides an overview of blast mechanics and pathophysiology. It details various blast-related injuries to the external, middle, and inner ear. Standard of care assessment and management strategies are presented for acute and late otologic sequelae of the blast-injured patient.