[Dilatational Tracheotomy in Head and Neck Surgery]. / Der Einsatz der perkutanen Dilatationstracheotomie im Rahmen der Kopf-Hals-Tumorchirurgie.

OBJECTIVE: The pre- and postoperative airway management during surgery of head and neck cancer is a clinically relevant and challenging task. Usually an epithelialised tracheostomy is used. The significance of percutaneous dilatational tracheostomy (PDT) in combination with tumour surgery of the head neck area has not yet been fully considered. MATERIAL AND METHODS: Within a surgical therapy of head neck tumours, 58 patients were treated with a PDT by Ciaglia or Fantoni at the Department of Otorhinolaryngology, Head and Neck Surgery, Martin-Luther-University Halle during the period from December 2002 to October 2007. The patient data were retrospective analyzed in a pseudonymous way. In a follow-up examination the resulting conditions of the PDT were reviewed. RESULTS: The median of the length of time till decannulation was 12 days. There were no documented disorders or complications after PDT at 25 patients (43%). As serious complications pneumothorax in 2 patients (3,4%), 9 bleedings (15,5%) and 1 infection (1,7%) were recorded. After occurrence of tracheostomy metastases in 2 patients with tracheostomy by Fantoni, this method was no longer used. For the subsequent follow-up examination 33 patients were included. No tracheal stenosis or serious long term complications were determined. CONCLUSIONS: Under consideration of the indications and contraindications, the percutaneous dilatational tracheostomy by Ciaglia with associated bronchoscopy is a safe method with low complication rate for the airway management of patients with head neck cancer. Long term complications and disorders after PDT are not to be expected. Tracheotomy according to Fantoni cannot be recommended for this treatment.

Expression and distribution of tenascin in rat submandibular glands following irradiation.

UNLABELLED: The aim of this study was to investigate the late changes in the expression of tenascin-C (TN-C) in salivary glands (SG) following irradiation (IRR). MATERIALS AND METHODS: In 124 submandibular SG from 62 Wistar rats, the effect of IRR dose (fractionated IRR, 2 Gy per day, total dose of 20, 40, or 60 Gy), time since IRR (6 months vs. 12 months), and animal age (1 year vs. 1.5 years) on TN-C expression profile and its distribution pattern was investigated. RESULTS: Expression of TN-C showed slight to moderate alterations in the irradiated specimens. The expression differed in frequency and degree among various tissue structures. The most striking finding was pronounced dose-dependent heterogeneity, with increases, decreases and fluctuations in staining. CONCLUSION: The staining of TN-C predominantly showed notable dose-dependent heterogeneity, persisting for up to 1 year after completion of IRR. Thus, these findings can be attributed to late radiation effects. The altered expression of tenascin-C may play at least a partial role in late radiogenic dysfunction of the submandibular SG.

[Atypical carcinoid of the larynx. Case report and review of literature]. / Atypisches Karzinoid des Larynx. Fallbericht und Literaturübersicht.

BACKGROUND: With an incidence of over 90%, squamous carcinomas are the most frequent laryngeal malignancies. Laryngeal neuroendocrine tumors appear only in approximately 1%. These are aggressive tumours with a high rate of metastases. To date, no diagnosis or treatment guidelines have been established for this entity. CASE REPORT: We describe the case of a 63-year-old man complaining of dysphagia and intermittent hoarseness. Initial laryngoscopy showed a tumour at the laryngeal epiglottic surface. Staging demonstrated an atypical carcinoid tumour with local lymph-node metastasis. At 24 months following revision surgery with safety distance, elective bilateral neck dissection and adjuvant radiotherapy the patient is free of complaints and recurrence. CONCLUSION: In atypical carcinoid tumours total resection as well as bilateral neck dissection should be performed, even in cN0 cases. In the presence of cervical lymph node metastases adjuvant radiotherapy is indicated.

[Therapeutic management of dislocated laryngeal fractures]. / Therapeutisches Vorgehen bei dislozierten Larynxfrakturen.

BACKGROUND: Acute trauma with laryngeal fracture is a rare injury affecting all functions of the larynx. Resuscitation follows the ABC principles for acute trauma life support. The priority has always been the establishment of an adequate and secure airway. To achieve optimal therapeutic long-term results, permanent stabilisation of the airway and good functional restoration of phonation and swallowing are necessary. We describe the therapy and long-term follow-up of two patients who suffered laryngeal fracture. CASE REPORTS: The first case concerns a 31-year-old woman who suffered polytrauma with laryngotracheal separation in a car accident. The fracture was reduced and fixed utilizing miniplates. After decannulation the patient had a patent airway. She regained normal voice and was able to swallow without difficulty. The other case concerns a 16-year-old boy who suffered a laryngeal fracture in a bicycle accident. He also underwent subsequent operative therapy using adaptation plates. This patient also regained an adequate airway and a good postoperative voice. There were no problems with swallowing. CONCLUSION: Chondrosynthesis with adaptation plates provides an enduring and exact fixation of laryngeal fractures. In the long term, this leads to a stable recovery of function concerning airway, voice, and swallowing.

Congenital malformations of the external and middle ear.

With the focus on imaging, this paper gives a summarized view of the present knowledge on fields, which are necessary to know for a profound understanding of congenital malformations of the external and middle ear. Typical and less typical combinations of malformed parts of the ear can be derived from the embryogenesis. Clinical signs and audiometric findings lead to diagnosis in congenital aural atresia. Isolated middle ear malformations can be clinically mixed up especially with otosclerosis and tympanosclerosis. Imaging is needed for exact morphological information. In malformations of the external and middle ear, CT is the imaging modality of choice. Requirements on CT-technique as well as radiological findings including classification and pre-surgical rating are described. Morphological CT-correlates of congenital malformations and their differential diagnoses are enlisted and illustrated. The impact of CT-results on therapy is explained and actual therapeutic concepts are briefly presented.

[Large endolymphatic duct and sac syndrome : part 2: clinical manifestations]. / Der erweiterte Ductus und Saccus endolymphaticus : Teil 2: Klinische Manifestationen.

OBJECTIVE: The aim of this study was to clarify the clinical course of large endolymphatic duct and sac syndrome (LEDS). Although LEDS is the most common form of radiologically detectable inner ear malformation associated with sensorineural hearing loss (SNHL), it is relatively unknown in the German-speaking countries. We hoped to derive useful pointers for clinical care. METHODS: We evaluated the clinical audiometric records and imaging findings of 169 patients with clinically suspected inner ear malformation seen between 1994 and 2003. Following identification of all LEDS cases, we serially investigated the anamnestic and functional data with regard to severity and course. RESULTS: Among 169 patients, 17 (median age 12 years; 12 females) showed LEDS. A total of 28 ears were affected. Clinically, most cases were of prelingual or perilingual onset and displayed steady or fluctuatingly progressive severe SNHL with emphasis on the high frequencies or deafness. Episodes of sudden hearing loss were relatively frequent. No correlation could be demonstrated between the severity of morphological changes and the degree of SNHL. CONCLUSION: Progression of SNHL and episodes of sudden hearing loss were seen mainly in late childhood or adolescence. This should be taken into account when informing and advising patients and planning therapy.

[Large endolymphatic duct and sac syndrome (LEDS) : part I: analysis of imaging findings]. / Der erweiterte Ductus und Saccus endolymphaticus : Teil 1: Analyse bildgebender Befunde.

OBJECTIVE: Large endolymphatic duct and sac (LEDS) syndrome is the most common radiologically detectable form of inner ear malformation (IEM) associated with sensorineural hearing loss (SNHL). Nevertheless, it is relatively unknown in the German-speaking countries. METHODS: Among all patients referred from ear, nose, and throat specialists to the radiology department with clinically suspected IEM between 1994 and 2003, we identified the cases of LEDS. The retrospective study included clinical records, high-resolution computed tomography, and magnetic resonance imaging. RESULTS: Of 169 patients, 17 (median age 12 years; 12 females) showed LEDS. A total of 28 ears were affected. Ten patients (6%; 15 ears) had isolated LEDS, while seven patients showed additional IEM (4%; 13 ears). The most frequent of these was dysplastic vestibule (13/13 ears), followed by Mondini deformity (10/13 ears) and dilated semicircular canals (7/13 ears). Three of 13 ears revealed severe IEM of the cochlea, vestibule, and semicircular canals. No correlation could be demonstrated between the severity of morphological changes and the degree of SNHL. CONCLUSION: LEDS may be an underestimated cause of SNHL. Imaging is necessary for a confident diagnosis.

Expression and distribution of cytokeratins and vimentin in rat larynx and trachea following irradiation.

BACKGROUND: External irradiation (IRR) of advanced head and neck tumors often includes tissues of the larynx and trachea unaffected by cancer. In these normal tissues, both single-cell damage (necrosis, apoptosis, functional cell death) and interstitial damage (edema, fibrosis, vascular alterations, cellular infiltrations) resulting in tissue remodeling can occur, depending on various IRR parameters. However, reports on radiogenic intermediate filament protein alterations in laryngeal-tracheal tissues are very rare. In this study, we investigated the phenotypic characterization of the normal integrity-supporting cytokeratins (CK) and vimentin following a clinically relevant IRR protocol in laryngeal-tracheal tissues. MATERIALS AND METHODS: In 61 laryngo-tracheal specimens from Wistar rats the expression profile and distribution pattern of CK (CK13, CK17/19, CK18) and vimentin were investigated according to IRR dose (fractionated IRR, 2 Gy per day, total dose of 20, 40 or 60 Gy), time from IRR (6 months vs. 12 months) and animal age (1 year vs. 1.5 years) using immunohistochemical methods, semiquantitative assessment and multivariate analysis. RESULTS: In irradiated specimens, expression of both CK and vimentin showed slight to moderate dose-dependent alterations. The expression differed in frequency and level among the various tissue structures and showed remarkable heterogeneity, with increases, decreases and fluctuations in staining. In the glottic mucosal layer (non-keratinizing squamous epithelium), CK13 expression decreased with increasing dose. The CK17/19 expression of supra- and subglottic respiratory epithelia following 20 and 60 Gy exposure was significantly lower than in controls. The respiratory epithelia and, in part, the cuboidal epithelia of the indifferent type at the inner side of the aryepiglottic fold revealed increasing CK17/19 immunoreactions up to 40 Gy IRR, but a distinct decrease in expression at 60 Gy. In subglottic gland structures, CK18 was detected at significantly higher levels than in controls. There was increasing expression with increasing dose. CK18 reactions of supra- and subglottic respiratory mucosal layer, supraglottic gland structures and thyrocytes tended towards increasing expression with increasing dose and in older animals. Tracheal mucosal epithelia, tracheal glands, and respiratory epithelia of the inner side of the aryepiglottic fold tended towards decreasing expression of CK18 with increasing dose and in older animals. In part, these tissues showed dose-dependent fluctuations. Furthermore, the vimentin reactions showed dose-dependent, heterogeneous patterns, with increases, decreases, and fluctuations in staining. Moreover, there were differences in frequency and intensity of expression among the various tissue structures. Age and time from IRR had no significant effect on immunoreaction. CONCLUSION: The staining of CK and vimentin predominantly showed a notable dose-dependent heterogeneity, with increases, decreases and fluctuations in expression. The expression pattern persisted for up to 1 year after the completion of irradiation. Thus, these findings must reflect late radiation effects. The altered expression of CK and vimentin may play at least a partial role in structural (e.g. edema) and functional (e.g. voice disorders) changes associated with irradiation of the head and neck.

[CT findings in isolated laryngeal trauma]. / Computertomographische Befunde beim isolierten Larynxtrauma.

UNLABELLED: The purpose of this article is a retrospective analysis of cases with suspected laryngeal trauma. The clinical importance, possibilities and limits of computertomographic diagnostics in laryngeal trauma are discussed. PATIENTS AND METHODS: Between 1992 and 2003 we performed high resolution computed tomography (CT) in 7 patients after an isolated laryngeal trauma with a standardized examination protocol. RESULTS: Following CT findings we made: one fracture of the thyroid cartilage, two fractures of the cricoids cartilage, one luxation of the arytenoids cartilage and four extensive soft tissue swelling of the larynx. One of the patients showed no lesions on CT. In another patient we found an intensive increase of density of arytenoids cartilage as sign of an arytenoids necrosis. CONCLUSION: High resolution spiral computed tomography is the method of choice to detect or exclude laryngeal fractures after an isolated neck trauma. Special parameters are necessary for detection of subtle pathological findings. In the estimation of mucosal or vocal cord changes the CT is inferior to endoscopy.

DNA-flow cytometry, DNA-image cytometry and proliferation index (MIB-5) in irradiated rat salivary glands and salivary gland tumors.

AIM: Salivary glands (SG) can become atrophic following radiation exposure. Malignant transformation of SG in a radiation field is another known sequela of patients who have been treated by radiotherapy for a malignant tumor in the head and neck region. The aim of this study was to investigate cytogenetic alterations and to determine the proliferation index (PI) of SG of rats subjected to various total dosages of fractionated X-rays. MATERIALS AND METHODS: We investigated rat SG, subjected to 20, 40, or 60 Gy exposure by X-rays to the left neck and skull base. Non-irradiated rats served as a control group. Tumors originating from the SG were histologically-diagnosed following the descriptions for human SG tumors. The MIB-5 antibody was used to determine the PI. The ploidy was determined by flow and image cytometry (FCM, ICM). RESULTS: We consistently recorded diploid histograms in the FCM in irradiated glands. ICM revealed aneuploid histograms in 6/22 tumors, 3 of them were Auer Type III or IV. The PI showed a dose- and time-dependent course, indicative of variable regeneration properties of the parenchyma. Statistically significant differences were found for the PI within the irradiation groups and comparing irradiated SG and tumors. CONCLUSION: Irradiation of rat SG can cause almost complete loss of function. On the other hand, the PI remained in animals subjected to 40 Gy and investigated 1 year after completion of radiation at a level up to 10-fold higher than in untreated controls. The PI in carcinoma is higher in this species than in irradiated SG. Constantly elevated PI could support the development of cancer in SG.

Potentials of ultrasound in the diagnosis of midfacial fractures*.

The aim of this study was to evaluate the application and limitation of ultrasound in the diagnosis of midfacial fractures. Eighty-one patients with radiologically proved fractures of the facial skeleton were included in this study. Examinations were performed using a 7.5-MHz small-part applicator. Another ten patients without facial fractures served as controls with normal sonoanatomical findings. The most important deficiency of ultrasound in the diagnosis of midfacial fractures is the difficult detection of non-dislocated fractures. According to our own experiences, the application of ultrasound in midfacial fractures is most useful for visualization of the zygomatic arch and the anterior wall of the frontal sinus, with immediate imaging after closed reduction avoiding radiation exposure. Moreover, it is restricted to fractures of the orbital margin and nasal bone. If ultrasound is performed as the first imaging modality in cases of suspected facial fractures by an experienced investigator, the visualization of fracture lines can avoid conventional imaging, so that only an indicated CT scan can be added. In doubtful cases, an individual combination of conventional radiographs would be the next step. By this, an overall reduction of radiation exposure seems possible.

[Intralesional cidofovir injections for recurrent laryngeal papillomatosis: first results]. / Intraläsionale Cidofovir-Injektion bei rezidivierender Larynxpapillomatose--Erste Ergebnisse.

BACKGROUND: The treatment of recurrent laryngeal papillomatosis still presents an important therapeutic problem. This primarily benign disease of the larynx is caused by an infection with the human papilloma virus (HPV) and forms epithelial neoplastic papillomas. Therapy in larynx obstructing papillomatosis usually requires laser ablation. Cidofovir acts virustatically as an nucleosidanalogon. Currently pilot studies investigate the effectiveness of intralesional Cidofovir injection. PATIENTS AND METHODS: The present study covers the period from October 2001 to March 2003. Seven patients, age of five to 70 years, were treated with intralesional injections of Cidofovir after microlaryngoscopic ablation of laryngeal papillomas. In all patients papillomatosis was confirmed histologically and a clinical-phoniatric examination and a photo documentation pre- and postoperatively was carried out. We treated patients to a maximum of six sessions. RESULTS AND CONCLUSIONS: After three to six sessions of laser ablation of the papillomas and intralesional injections with Cidofovir a distinct papilloma reduction could be observed in all patients and in two cases a complete remission was achieved. The follow-up period of seven to 15 months revealed no recurrent laryngeal papillomatosis. The majority of patients showed a defined voice improvement. There were no local or systemic side-effects caused by the virustatic drug. Intralesional injection of Cidofovir appears to develop into a promising adjuvant therapy option in recurrent laryngeal papillomatosis. First results of the study seem to achieve a considerable reduction of the previously high rate of recurrence of laryngeal papillomatosis.

Expression and distribution of basement membrane proteins in rat larynx and trachea following irradiation.

OBJECTIVE: Basement membranes-(BM) influence polarization, differentiation, migration and proliferation of cell and play an important role in maintaining structural and functional tissue integrity. While BM alterations have been reported in various lesions (e.g. inflammation, tumors) of laryngeal-tracheal tissues, reports on radiogenic BM alterations are rare. External irradiation (IRR) of advanced head and neck tumors often includes "normal tissues" (tissues without cancer) of the larynx. In these normal tissues both single-cell damage (necrosis, apoptosis, functional cell death) and interstitial damage (edema, fibrosis, vascular alterations, cellular infiltrations) resulting in tissue remodeling can occur, depending on various IRR parameters. In this study, we set out to add to our knowledge on the phenotypic characterization of the radiogenic BM expression pattern in laryngo-tracheal tissues. MATERIALS AND METHODS: In 63 laryngo-tracheal specimens from Wistar rats, we investigated the laminin (LA) and collagen IV (CIV) expression profile and distribution pattern depending on the IRR dose (fractionated IRR, 2 Gy/day, up to a total dose of 20, 40, or 60 Gy), the time since IRR (6 months vs 12 months) and animal age (1 year vs 1.5 years) using immunohistochemical methods, semiquantitative assessment, and multivariate analysis. RESULTS: In specimens irradiated with more than 20 Gy, both BM constituents predominantly showed dose-dependent increases and sometimes fluctuations in staining at slight to moderate levels. The expression differed in frequency and level among the various tissue structures. In some structures there was decreased expression. In the vocalis muscle, laryngeal and esophageal nerve endings, recurrent laryngeal nerve and laryngeal and tracheal muscles, LA was detected at levels significantly stronger than in controls. BM surrounding gland structures, nerve endings of the piriform sinus and esophageal muscles showed a marked tendency towards increased LA expression. However, the BM underlying the mucosal layer of the supra- and subglottic region revealed decreasing LA immunoreaction up to 40 Gy IRR, but a distinct increase in expression at 60 Gy. In the esophageal and tracheal muscles, tracheal perichondrium, recurrent laryngeal nerve and capillaries, CIV was detected at significantly stronger levels than in the controls. The vocal ligament exhibited positive CIV immunoreactions adjacent to interstitial and infiltrate cells and CIV-positive BM condensations, resulting in increased staining of these structures. CIV reactions of laryngeal and hypopharyngeal nerve endings tended towards increased expression. In contrast, BM staining surrounding vocal muscle cells revealed significantly decreased expression. In addition, there was a tendency towards decreased expression for supraglottic, subglottic and hypopharyngeal muscle cells. Age and time since irradiation had no significant effect on staining. CONCLUSION: The BM constituents laminin and collagen IV showed prominent dose-dependent increases and sometimes fluctuations in expression. This expression pattern persisted up to one year after completion of the irradiation. Thus, these findings must be related to late radiation effects. The altered BM expression may play a role, at least in part, in structural (e.g. laryngeal edema) and functional (voice disorders) changes associated with irradiation of the head and neck area.

The expression pattern of collagen I in irradiated mandibular salivary glands of rats.

UNLABELLED: Irradiation damage to salivary glands leads to loss of function and fibrosis. Immunohistochemical analysis of extracellular matrix proteins might give a more precise insight into the irradiation damage of glands. Collagen I (C-I) is a major component of the extracellular space. The aim of this study was to analyse the effects of irradiation on the distribution pattern of C-I in the salivary glands of rats. MATERIALS AND METHODS: Sixty female Wistar rats were fractionated irradiated up to 60 Gy (left side of the neck; 2 Gy/d, 5d/week; total dosage either 20, 40 or 60 Gy). The glands were explanted after 6 or 12 months following supravital anesthesia, the shielded right gland serving as internal control. C-I was detected immunohistochemically. RESULTS: In non-irradiated animals the immunoreaction was mainly homogeneous and slight around the ductal epithelia, in the area of the capsule and septae and the peri- and epineurium of nerves. A statistically significant difference was identified in the irradiated rats vs control animals and comparing in-the-radiation field (left side) vs outside-the-radiation field (right side) situated glands. Multivariate analysis revealed a statistically significant increase in staining of irradiated rats concerning the excretory ducts, the area of the capsule and septae, the nerves and striated ducts and adventitia of vessels [p = 0.0001]. The increase of immunoreaction in irradiated glands started above 20 Gy total dosage and was at its maximum after 60 Gy. However, the expression profile was inhomogenous following 20 Gy exposure and did not differ statistically from glands of control animals. Neither the age of the animals nor the latency period following exposure to the radiation source yielded a statistically significant effect on the immunoreaction. CONCLUSION: Studies on irradiation damage to the salivary glands require a more detailed description of the proteins accumulating in the extracellular space, thereby forming the so-called "fibrosis". These accumulations of proteins, e.g. C-I, may both support apoptosis and support a hypoxic environment giving rise to transformed cells.

[Furlow palatoplasty--experiences with 114 consecutive cases]. / Die Gaumenplastik nach Furlow--Erfahrungen an 114 konsekutiven Fällen.

After introducing the Furlow's double opposing palatoplasty [4] in our clinic in 1991 114 patients were operated on and registered prospectively. Using this procedure for closure of small clefts and/or with moderate velopharyngeal incompetence only at the beginning it became the method of choice not only for primary palatoplasty at the age of 18-24 months but also for corrective measures now. An increase of length of the soft palate of 10 +/- 3 mm at the average was gained immediately after surgery. There were no specific side effects of the method, especially no fistulas occurred. Good speech results were obtained in 61% at the age of 8 years using profound phoniatric tests. Mixed velopharyngeal closure investigated by means of nasal videoscopy was the dominating form in 55%. The results underwent a positive change comparing results in patients after longitudinal investigation at the age of 5 and 8 years bzw. They corresponded with or exceeded the results found in a control group operated on with other methods of palatoplasty at another centre.

[Immunohistochemical detection of hormones in hypophyseal adenomas of the rat after fractionated irradiation]. / Immunhistochemischer Nachweis von Hormonen in Hypophysenadenomen der Ratte nach fraktionierter Bestrahlung.

BACKGROUND: The aim of this study was to determine the hormones produced in pituitary gland tumours (TM) following fractionated external irradiation in rats. The TM arose in the course of studies on other questions of radiation effects. METHODS: The left neck and skull base of sixty female Wistar rats, 3 to 4 months of age at the beginning of the external irradiation, were subjected to roentgen rays exposure, fractionated to 2 Grays daily, either up to 20, 40 or 60 Gy. The midline of the neck and skull was always inside the radiation field. The animals were sacrificed either 6 months or 12 months after completion of the randomly assigned irradiation protocol. Five non-irradiated rats served as controls. RESULTS: No TM developed in the non-irradiated animals. Out of 60 irradiated rats 9 developed a pituitary TM (15%). In remnants of the normal adenohypophysis we revealed immunohistochemical reactivity for growth hormone (GH), adrenocorticotropic hormone (ACTH), prolactin (PRL), thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH). In the radiation-induced adenomas, 4 TM were immuno-reactive for TSH, 4 for GH, 2 for PRL, and 2 for FSH. The TM did not react with anti-ACTH and anti-LH (luteinizing hormone) anti-sera. CONCLUSIONS: Obviously, irradiation accelerates the development of pituitary gland adenomas. In this series the TM were predominantly incidental findings at necropsies after pretermed follow-up intervals with a variety of hormone-producing cells. On the other hand, four of nine TM were null adenomas. Necropsies of the brain should be carried out routinely in irradiation studies of the skull.

Limitations of B-scan ultrasound for diagnosing fractures of the mandibular condyle and ramus.

The aim of this study was to analyse the applications and limitations of B-scan ultrasonography for diagnosing fractures of the mandibular condyle and ramus. Thirty-two patients with 39 radiologically proven fractures of the mandibular condyle and ramus were included in the study. The patients were examined with a 7.5 MHz small-part applicator. Five patients without fractures of the facial skeleton acted as controls. Normal sonoanatomical findings had been obtained for patients without mandibular fractures. B-scan ultrasonography enabled the experienced examiner to identify dislocated fractures of the mandibular ramus and the articular process in 67% of the fractures. The main disadvantage of ultrasonography was the inability of this technique to identify non-dislocated fractures. Because of its low sensitivity and specificity, B-scan ultrasonography does not provide an alternative to X-ray diagnosis of mandibular condyle and ramus fractures.