A new radiological classification for the risk assessment of anterior skull base injury in endoscopic sinus surgery.

Keros and Gera classifications are widely used to assess the risk of skull base injury during endoscopic sinus surgery. Although, both classifications are useful preoperatively to stratify risk of patients going for surgery, it is not practical to measure the respective lengths during surgery. In this study, we aimed to propose a new radiological classification (Thailand-Malaysia-Singapore (TMS)) to assess the anatomical risk of anterior skull base injury using the orbital floor (OF) as a reference. A total of 150 computed tomography images of paranasal sinuses (300 sides) were reviewed. The TMS classification was categorized into 3 types by measuring OF to cribriform plate and OF to ethmoid roof. Most patients were classified as TMS type 1, Keros type 2 and Gera class II, followed by patients classified as TMS type 3, Keros type 1 and Gera class 1. TMS has significant correlation with Keros classification (p < 0.05). There was no significant correlation between Keros and Gera classifications (p = 0.33) and between TMS and Gera classifications (p = 0.80). The TMS classification has potential to be used for risk assessment of skull base injury among patients undergoing ESS. It serves as an additional assessment besides the Keros and Gera classifications.

Pituitary and skull-base lesions and the litigious patient.

BACKGROUND: The objective of this research was to evaluate litigation relating to the diagnosis and management of pituitary and ventral skull base lesions and delineate allegations involved in the decision to pursue medicolegal proceedings. METHODS: Publically available federal and court records were accessed via the Westlaw Next database. Jury verdict and settlement reports relevant to pituitary and anterior skull-base lesions were accessed, and litigation was reviewed for alleged injuries, defendant specialty, patient demographics, and other factors raised in proceedings. RESULTS: Of 75 cases included, 50.7% were resolved in the defendant's favor. The most frequent physician specialties cited as defendants included primary care (20%), neurosurgery (17%), and radiology (16%), while otolaryngologists were defendants in only 5% of cases. Fifty-two (69%) did not involve surgical intervention; the most common allegations in these proceedings were misdiagnosis, permanent injury (19%), requiring additional procedures as a result of misdiagnosis (17%), permanent endocrine dysfunction (14%), and visual sequelae (12%). Among surgical cases, the most common allegations raised included permanent injury (17%), postoperative complications (14%), intraoperative complications (13%), and death (10%). Among cases resolved with payment, there was no statistical difference in payment between surgical cases ($5.7M) and nonsurgical cases ($4.8M). CONCLUSION: Misdiagnosis of endocrinopathy, failure to appropriately workup patients presenting with neurologic complaints, and radiologic misdiagnosis play important roles in the pursuit of litigation in nonsurgical cases. Sustaining permanent sequelae including endocrine and visual injury play an important role in surgical cases. Postoperative management appears to play just as important a role in the decision to pursue litigation as intraoperative considerations.

Massive hemorrhage in facial fracture patients: definition, incidence, and management.

BACKGROUND: Significant hemorrhage from fractures of the midface is a recognized phenomenon, but because it is an uncommon occurrence, there is little in the literature to guide management of these patients. METHODS: The authors performed a retrospective study of life-threatening hemorrhage in facial fracture patients attending the Royal Adelaide Hospital over 20 years and report four recent cases. RESULTS: The incidence of massive hemorrhage was found to be 0.33 percent of patients with fracture of the midface or skull base over the 20 years before 2004 and 1.7 percent in the subsequent year. Of the 19 patients identified from case notes and recent experience, seven died. In terms of management of hemorrhage, three patients had packing alone, 10 had balloon catheters inserted, and five had ligation of a vessel. Most patients had multiple other injuries, including six patients with head injuries. The mean number of units of packed red cells transfused was 9.5 (median, 7.5). In five of the cases identified, there was a delay in recognizing that facial fractures were the major source of hemorrhage. CONCLUSIONS: Massive hemorrhage from facial fractures is an underrecognized and inconsistently managed phenomenon. Although low in incidence, its timely recognition and better management may reduce the high mortality rate in this group of patients.

The cervicocranium: its radiographic assessment.

Acute injuries of the cervicocranium (from the occiput to the second cervical intervertebral disk) may be radiographically obscure due to minimal displacement of fracture fragments, minor alterations of normal anatomic relationships (occipitoatlantal subluxation), or superimposition of normal skeletal structures. With the nasooropharynx adequately distended with air, the normal cervicocranial prevertebral soft-tissue contour is congruent with the anterior cortical margin of the cervicocranium; namely, concave above, convex anterior to, and concave below the anterior tubercle of C1. Alterations of the normal cervicocranial prevertebral soft-tissue contour due to hemorrhage into the retropharyngeal fascial space from subtle fractures or ligamentous injuries should prompt further assessment of the cervicocranium by means of computed tomography (CT). Cervicocranial CT prompted by an abnormal cervicocranial prevertebral soft-tissue contour has yielded a 16% positive injury rate, approximately three times the rate of acute cervical spine injuries reported in the literature.