The Use of Brainlab Navigation in Le Fort III Osteotomy.

Le Fort III osteotomy is commonly used in the surgical correction of midface hypoplasia, specifically in patients with syndromic craniosynostosis. These osteotomies can be associated with significant complications, which are often the result of incomplete or inaccurate osteotomies. Brainlab, a technology first developed for neurosurgery, has been applied to numerous surgical subspecialties. The aim of this study was to report our initial experience using the Brainlab VectorVision2 and Brainlab Curve (Brainlab, Westchester, IL) as an intraoperative guidance system for osteotomy placement during Le Fort III advancement. Three pediatric patients with syndromic craniosynostosis and midface hypoplasia scheduled to undergo Le Fort III advancement were scanned preoperatively with 0.6-mm computed tomography cuts, which were then uploaded to the Brainlab system. All surgeries commenced with rigid fixation of the Brainlab registration device to the patient's skull. The navigation system was used intraoperatively to accurately determine osteotomy sites and trajectories. External distractors were placed without complication. Mean length of surgery was 331 minutes, and mean estimated blood loss was 500 mL. No transfusion was required with a mean postoperative hemoglobin of 8.3 g/dL. The application of Brainlab technology to Le Fort III advancement proved useful in establishing precise osteotomy lines and trajectories. Looking forward, this technology could be applied to a minimal dissection technique in order to avoid extensive blood loss. Further study would be needed to determine possible benefits such as reduced complications or operative time when using an intraoperative navigation system for image-guided osteotomy placement during Le Fort III advancement.

Pediatric frontal mucocele secondary to a bifid frontal sinus septum.

A mucocele is a mucus-containing sac lined with epithelium that arises within a sinus when its drainage is compromised. The frontal sinus is the most common location, with frontal mucocele development occurring when the nasofrontal duct becomes obstructed because of polyps, bone tumors, prior surgery, sinusitis, trauma, or anatomic variation. We report an unusual case of a sterile pediatric frontal mucocele presenting as a slowly enlarging forehead mass due to a bifid frontal sinus septum. A 9-year-old girl presented to the craniofacial clinic for evaluation of a right frontal mass that had been slowly growing over the past year. She was otherwise healthy and had no history of previous trauma or sinus infections. Computed tomography (CT) scan results revealed a localized frontal fluid collection with protrusion and thinning of the anterior frontal bone between 2 midline bony septii. Surgical cranialization of the frontal sinus was performed. The anatomy of her lesion seen both on CT scan and intraoperatively likely explains this unusual case presentation. Instead of the usual inciting event of an intact frontal sinus drainage system becoming blocked, this patient seemed to have a primary developmental lack of any drainage system that led to her mucocele. During formation of her frontal sinus, she developed a bifid septum within the midline that excluded a portion of her frontal sinus from the lateral nasofrontal ducts. With mucus-producing epithelium trapped within these bony confines, pressure began to mount with expansion and thinning of the bone both anteriorly and posteriorly. The lack of any infectious symptoms and sterile culture results may support that this space developed primarily and was never in continuity with the external drainage system. Only 4 other patients have been reported with asymptomatic forehead swelling as the only presenting symptom, with the age ranging from 33 to 79 years. This patient represents the first clinical report of a congenital developmental mucocele.

Incidence of otitis media in children with deformational plagiocephaly.

In the past decade, deformational plagiocephaly has seen a staggering increase attributed to the Back to Sleep Campaign of April 1992. With this increase, the possible clinical associations need to be fully understood. The anatomic changes seen include ipsilateral occipital flattening, ipsilateral frontal bossing, ipsilateral anterior ear displacement, contralateral occipital bossing, and contralateral frontal flattening [J Craniofac Surg 2004;15:368-372, erratum in J Craniofac Surg 2004;15:705; Fig. l]. Children with deformational plagiocephaly can have malpositioned ears affecting normal drainage of the eustachian tube as it shifts with this deformity. The eustachian tube plays an important role in draining the middle ear. As evidenced by children with cleft palates, structural differences in the anatomy of the middle ear and eustachian tube can result in an increased susceptibility to otitis media. An institutional review board-approved retrospective study was conducted on all patients whose conditions were diagnosed as deformational plagiocephaly from a cleft and craniofacial deformities clinic for a 2-year period. Parents of patients self-reported the number of ear infections on a questionnaire. The questionnaire results were compared to age-matched patient data available from the Center for Disease Control. There were 1259 patients who fit the inclusion criteria for the questionnaire part of the study, and of these, 634 (50.4%) reported at least 1 ear infection by 1 year of age. In addition to the questionnaire, a subset of infants with deformational plagiocephaly up to 1 year of age were administered a tympanogram, to assess the state of the middle ear. There were 124 patients who fit the inclusion criteria for the tympanometry part of the study, and of these 121 had an abnormal tympanogram at 1 or more clinic visits. The questionnaire did not show deformational plagiocephaly to be a significant risk factor for otitis media in our patient population; however, a trend directly correlating otitis media and the severity level of deformational plagiocephaly was observed. Although this trend lacked statistical significance, further studies should explore these differences. Tympanogrametry showed a marked percentage of infants with deformational plagiocephaly to have eustachian tube dysfunction. Future studies will focus on the significance of these findings.