Predictors of Infection and Benefit of Antibiotics in Gunshot Wounds to the Face.

BACKGROUND: Gunshot wounds (GSWs) to the face are at high risk for infection due the extent of tissue injury and often-observed violation of oral and sinus cavities. Given the ambiguous data on antibiotic benefit in GSW to the face, the purpose of this study is to characterize antibiotic usage, infection details, and risk factors associated with higher infection rates in GSW to face. METHODS: We conducted a retrospective review of patients presenting with GSW to the face from 2009 to 2017. The primary outcome was to identify risk factors associated with infections in patients with facial GSWs. A stepwise multivariate linear regression analysis was performed to determine the impact of specific injury details. RESULTS: Two hundred sixty-nine patients qualified for the study. Demographic information and details of hospital stay are presented in tables. Most patients (88.8%) received admission antibiotics. Facial infections were observed in 36 patients (13.4%). The infected cohort required more antibiotic days (P < 0.001), higher percentage of invasive airway procedures (P = 0.01), longer length of stay (P < 0.001), greater number of surgeries (P < 0.022), and higher readmission rates (P < 0.001). Factors associated with head or neck infections included oral cavity (odds ratio, 1.23; P = 0.04) and sinus involvement (odds ratio, 1.10; P = 0.045). CONCLUSIONS: Bullet trajectories that violated the oral or maxillary sinus cavities were associated with higher head and neck infection rates. Patients without oral cavity or sinus involvement had a lower chance (4.1%) of developing an infection and therefore may have marginal benefit from antibiotics.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

BACKGROUND: Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. METHODS: A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. RESULTS: Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. CONCLUSIONS: Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.

Pediatric facial reanimation: An algorithmic approach and systematic review.

Facial palsy has a broad clinical presentation and the effects on psychosocial interaction and facial functions can be devastating. Pediatric facial palsy, in particular, introduces unique familial and technical considerations as anatomy, future growth potential, and patient participation influence treatment planning. Though some etiologies of pediatric facial palsy are self-limiting, congenital and long-standing facial palsies pose difficult challenges that require a combination of surgical, adjunctive, and rehabilitative techniques to achieve facial reanimation. Given the spectrum of ages and symptom severity, as well as the various surgical options available for facial palsy, a tailored approach needs to be developed for each child to restore facial balance and function. Here, we review the etiologies, workup, and treatment of pediatric facial palsy and present our novel algorithmic approach to treatment.

Near miss for big red: a unique case of penetrating glass injury of the thoracic spine and posterior mediastinum.

INTRODUCTION: A 42-year-old female with no significant comorbidities presented to our care with a penetrating glass injury to her mid-thoracic spine after falling backwards onto a table. CASE PRESENTATION: A large fragment of glass was protruding from her spine, and multi-planar computed tomography imaging revealed protrusion through the thoracic spinal vertebrae with the glass shards located 2 mm from the aortic lumen. The management of this patient posed several challenges, including initial care of the patient, evaluation of potentially affected structures and the appropriate sequence of therapeutic interventions. After multidisciplinary discussion, our trauma, thoracic and neurosurgical teams formulated a diagnostic workup and two-step surgical approach to address her injuries. DISCUSSION: Here we present the approach used by our team to successfully manage this type of injury. We hope this case report represents a platform for future discussion on best management approaches in patients presenting with the low-velocity penetrating thoracic, spinal and posterior mediastinal trauma.