Subcranial craniotomy approach for frontobasal fracture correction.

OBJECTIVE: Frontobasilar fracture types and the outcome of patients after management with the subcranial approach technique were evaluated. MATERIAL AND METHODS: A retrospective analysis of 48 patients (45 males, mean age 38,5 years; range 16-82 years) who had a subcranial approach for frontal base fracture correction between April 1996 and April 2011 at a tertiary care academic hospital in Turku, Finland. RESULTS: Sixteen (33%) patients had fractures including all frontobasilar fracture types (Type I-IV) i.e. fractures that involved frontal sinuses, orbital roofs, ethmoidal region, cribriform plate and sphenoidal region. Twenty-seven (56%) patients were considered to have had brain damage at presentation. Forty percent of patients were suffering from synchronous trauma. Peroperatively, 31 (65%) patients had exposure or defect of the dura due to bone dehiscence but only two patients suffered from cerebrospinal fluid (CSF) fistula following surgery. CSF fistulae were covered by pericranium in most of the cases (68%). There was no postoperative meningitis. Thirty-eight percent of the patients needed further operation with a subcranial craniotomy following primary reconstruction. At the last follow-up visit 35% were suffering from permanent neurological problems following brain injury. CONCLUSIONS: Subcranial approach seemed successful in the management of all frontobasilar fractures in this series with reasonably low complication rate. Therefore, we would recommend it as the technique of choice in multiple and even in the most complicated frontal base fractures.

Frontobasilar fractures: proposal for image reviewing algorithm.

OBJECTIVE: The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface. MATERIAL AND METHODS: The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports. RESULTS: The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed. CONCLUSIONS: Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.

Post-traumatic morbidity is frequent in children with frontobasilar fractures.

OBJECTIVE: Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity. METHODS: A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger. RESULTS: The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae. CONCLUSIONS: Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.

Management and outcome of pediatric skull base fractures.

OBJECTIVE: The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures. METHODS: Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed. RESULTS: A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome. CONCLUSIONS: We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.

Acute dysphagia associated with aortic dissection: a case report and review of the literature.

Thoracic aortic aneurysm and dissection are rare causes of neurologic symptoms as well as of dysphagia. We report on a 58-year-old otherwise healthy male patient who presented with acute-onset intermittent dysphagia, mild dyspnea, and chest symptoms. He was referred to an emergency ENT unit for a suspected peritonsillar abscess but died of a massive aortic dissection and cardiac tamponation a few hours later. This rare condition is discussed in the differential diagnosis of adult acute-onset dysphagia.

Differences in the location and multiplicity of mandibular fractures in Kuwait, Canada and Finland during the 1990s.

OBJECTIVE: To compare the location and multiplicity of mandibular fractures in Kuwait, Canada and Finland during the 1990s. SUBJECTS AND METHODS: Data were collected from several hospitals in Kuwait (1991-2000), Toronto General Hospital in Canada (1995-2000) and Oulu University Hospital in Finland (1990-1999). The data were analyzed statistically using chi-square test, ANOVA, t test and logistic regression. RESULTS: Condylar fractures were more common in Finnish patients (41%) than Canadian (35%) or Kuwaiti patients (21%). Condylar fractures caused by falls were about 3.4 times more common in Kuwait and Finland compared to Canada. In Finland the risk of road traffic accidents caused by condylar fracture was about 4 times higher than those caused by other etiologies. In Canada male gender was about 2 times higher for the condylar fracture than female gender. Female patients often had more multiple injuries than men in all three countries and multiple fractures were observed especially in traumas caused by falling. CONCLUSION: Differences in location and multiplicity of mandibular fractures are due to differences in etiologies and demographic patterns.