Pediatric ping-pong skull fractures treated with vacuum-assisted elevation.

PURPOSE: Depressed ("ping-pong") skull fractures can be treated by different means, including observation, non-surgical treatments, or surgical intervention. The authors describe their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate variables associated with surgical outcomes. METHODS: The authors present a retrospective review of all ping-pong skull fractures treated with vacuum-assisted elevation at the Children's Hospital of Orange County in 2021-2022. Variables included patient age, mechanism of injury, fracture depth, bone thickness at the fracture site, and degree of elevation. RESULTS: Seven patients underwent vacuum-assisted elevation of ping-pong fractures at the bedside without the use of anesthesia. Fractures caused by birth-related trauma were deeper than those caused by falls (p < 0.001). There was no significant difference between groups in bone thickness at the fracture site (2.10 mm vs 2.16 mm, n.s). Six of the seven patients experienced significant improvement in fracture site depression, with four displaying a complete fracture reduction and two displaying a significant reduction. The degree of fracture reduction was modestly related to the depth of fracture, with the two deepest fractures failing to achieve full reduction. Age appeared to be related to fracture reduction, with the lowest reduction observed in one of the oldest patients in this sample. No complications were observed in any patient other than temporary mild swelling at the suction site, and no re-treatment or surgery for the fractures was required. CONCLUSION: Vacuum-assisted elevation of ping-pong skull fractures is a safe and effective noninvasive treatment option for infants that can be used under certain circumstances. The procedure can be done safely at the bedside and is a relatively quick procedure. It avoids the need for open surgical intervention, anesthesia, or hospital admission, and can lead to excellent outcomes.

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture.

CONTEXT: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

[Determination of severity of harm caused to health in depressed skull deformation by «ping-pong¼ type in an infant]. / Opredelenie stepeni tyazhesti vreda, prichinennogo zdorov'yu, pri vdavlennoi deformatsii cherepa po tipu «ping-pong¼ u mladentsa.

THE OBJECTIVE: Is to develop a differential approach to determining the severity of harm caused to health in case of depressed skull injuries in infants, depending on their morphological features and the character of required treatment. The material included data from literature sources on the study of brain injuries in infants, clinical guidelines, describing the features of clinical picture and diagnosis of depressed skull fractures in infants and legal and regulatory framework of forensic medical evaluation of harm caused to health in injury. The following methods of research were used: logical-analytical, logical-synthetic (generalization), comparative, system-analytical (analysis of relations between facts) and radiological method. An algorithm for determining the severity of harm caused to health in depressed skull deformations by «ping-pong¼ type in an infant is proposed for discussion. The algorithm is based on the data from injury imaging techniques, including X-ray computed tomography, takes into account the clinical picture and the availability of indications for surgical treatment, and will allow to objectively assess the severity of harm caused to health in such cases.

Depressed skull fracture compressing eloquent cortex causing focal neurologic deficits.

BACKGROUND: Depressed skull fractures are typically the consequence of high-impact injuries with inward buckling of the cranium. The majority of depressed skull fractures are managed conservatively in the absence of dural violation, sinus involvement, significant underlying hematoma, depressed fragment greater than 1 cm, wound infection, or gross wound contamination. Even in the presence of any of the aforementioned criteria, cranioplasty is typically considered an urgent procedure rather than a neurosurgical emergency. Rarely, a depressed fracture fragment can cause focal neurologic deficit(s) due to direct compression of the underlying eloquent cortex. CASE DESCRIPTION: A 40-year-old male presented to the emergency department after a mechanical fall with a left central facial nerve palsy, left hemiplegia, left hemianesthesia, and fixed right gaze deviation. The neurologic deficits observed were attributed to a combination of blunt force trauma to the head (i.e., coup-contrecoup injury) and the depressed fracture fragment compressing the underlying eloquent cortex. He underwent emergent cranioplasty with fragment elevation within 2 hours of the traumatic injury. At 6-month follow-up, he regained full neurologic function without any residual deficits. CONCLUSIONS: Our experience highlights a rare indication for emergent cranioplasty with an excellent functional outcome attributable to immediate fracture elevation and decompression of eloquent cortex.

Fractura con hundimiento de cráneo intrauterina espontánea: reporte de dos casos / Spontaneous intrauterine depressed skull fracture: report of two cases

Las fracturas con hundimiento de cráneo intrauterinas representan una entidad poco frecuente, generalmente secundaria a traumatismos (previos o durante el nacimiento) o de etiología desconocida. Suelen requerir evaluación y seguimiento por el servicio de Neurocirugía Pediátrica. A la fecha, es controversial la necesidad de tratamiento quirúrgico y el momento oportuno para concretarlo. Se presentan dos casos clínicos de pacientes de término, nacidas porcesárea,condiagnósticoposnatalinmediatodehundimiento de cráneo de tipo ping-pong no traumático. Ambas pacientes presentaron examen neurológico normal. Se confirmó el diagnóstico a través de radiografía y tomografía de cráneo, sin observarse lesiones asociadas. Fueron valoradas por el servicio de Neurocirugía, que indicó corrección quirúrgica de la lesión en ambos casos, con buena evolución posterior.

Spontaneous intrauterine depressed skull fractures are a rare entity. They can appear secondarily to head trauma (before or during birth) or due to unknown etiology. They usually require a complete evaluation from pediatric neurosurgery specialists. Their optimal management, including timely surgical treatment remains controversial. We describe two cases delivered by cesarean section, with postnatal diagnosis of spontaneous intrauterine depressed skull fracture. Both had a normal neurological exam. A skull radiography and head CT were performed, and no associated lesions were found. Both cases required surgical correction, with positive results.

[Spontaneous intrauterine depressed skull fracture: report of two cases]. / Fractura con hundimiento de cráneo intrauterina espontánea: reporte de dos casos.

Spontaneous intrauterine depressed skull fractures are a rare entity. They can appear secondarily to head trauma (before or during birth) or due to unknown etiology. They usually require a complete evaluation from pediatric neurosurgery specialists. Their optimal management, including timely surgical treatment remains controversial. We describe two cases delivered by cesarean section, with postnatal diagnosis of spontaneous intrauterine depressed skull fracture. Both had a normal neurological exam. A skull radiography and head CT were performed, and no associated lesions were found. Both cases required surgical correction, with positive results.

Las fracturas con hundimiento de cráneo intrauterinas representan una entidad poco frecuente, generalmente secundaria a traumatismos (previos o durante el nacimiento) o de etiología desconocida. Suelen requerir evaluación y seguimiento por el servicio de Neurocirugía Pediátrica. A la fecha, es controversial la necesidad de tratamiento quirúrgico y el momento oportuno para concretarlo. Se presentan dos casos clínicos de pacientes de término, nacidas por cesárea, con diagnóstico posnatal inmediato de hundimiento de cráneo de tipo ping-pong no traumático. Ambas pacientes presentaron examen neurológico normal. Se confirmó el diagnóstico a través de radiografía y tomografía de cráneo, sin observarse lesiones asociadas. Fueron valoradas por el servicio de Neurocirugía, que indicó corrección quirúrgica de la lesión en ambos casos, con buena evolución posterior.

[Depressed skull fractures in newborns. Case report of ping-pong fracture and literature review]. / Vdavlennye perelomy svoda cherepa u novorozhdennykh. Klinicheskii sluchai tipa «ping-pong¼ i obzor literatury.

Depressed skull fractures (ping-pong) in the fetus and newborn are associated with birth canal pathology, maternal trauma and birth trauma following instrumental delivery. The authors report a newborn with a depressed skull fracture (ping-pong) who underwent minimally invasive neurosurgical lifting of bone fragment through a burr hole. Strategy and methods of treatment of similar depressed skull fractures were comprehensively discussed. Moreover, the authors proposed a brief algorithm for the use of vacuum systems and various surgical techniques, including follow-up depending on type, cause, size of the fracture and concomitant intracranial lesions.

Seemingly inconsequential yet catastrophic: the importance of wound washout with minute depressed skull fracture from a dog bite.

Depressed skull fractures from dog bites are common pediatric head injuries which are contaminated with native skin and canine oral flora. Outcomes can potentially be catastrophic. Thus, these injuries require proper initial management to prevent future complications. We present an 18-month-old female who was bitten by a Great Dane dog and resulted in a small left temporal depressed skull fracture with an underlying brain contusion. This was initially treated conservatively with antibiotics and bedside irrigation. Five weeks later, she developed a large multiloculated abscess with mass effect, which required surgical aspiration and wound debridement. After long-term antibiotics, she made a full neurologic recovery. Our case illustrates the importance of washing out a seemingly inconsequential depressed skull fracture from a dog bite to avoid development of a cerebral abscess.

Airgun Wound with Superior Sagittal Sinus Involvement in a Child: Case Report and Review of the Literature.

INTRODUCTION: Although still considered quite harmless, nonpowder guns (NPG) may cause severe head injuries in children. We present the case of a depressed skull fracture with superior sagittal sinus involvement following NPG injury. Decision-making and surgical management are discussed, and the current literature concerning NPG-related pediatric head injuries is reviewed. CASE PRESENTATION: A 4-year-old boy hit by a compressed-air rifle came to our center. CT scan showed a depressed skull fracture of the occipital bone on the midline and intracranial penetration of some fragments of the pellet. CT angiography documented a compression of the superior sagittal sinus without thrombosis. Soon after hospital admission, the patient showed deterioration of the neurological status suggesting intracranial hypertension. Surgery was performed with fracture elevation, removal of metal fragments, and wound debridement. The patient had a full recovery without subsequent neurological deficits. DISCUSSION/CONCLUSION: Modern airguns may produce severe penetrating head injuries in children. Parents and physicians should be aware of the danger of NPG. Depressed skull fracture and dural venous sinus involvement can occur, and even a stable neurological condition may worsen. In such instances, a thorough preoperative assessment including vascular imaging is mandatory. The surgical risk is not negligible due to the possible injury of the sinus wall and subsequent intraoperative bleeding. This has to be weighted against potential complications of the penetrating injury, such as infection, sinus thrombosis, and intracranial hypertension. Our case suggests that prompt surgical treatment can be a safe and effective option.

Use of Vacuum-suction in Depressed Skull Fractures ­ Case Report and Technical Nuances of Nonoperative Treatment

Up to 20% of victims from skull fractures are represented by the pediatric population, and 50% of these lesions are depressed skull fractures. The treatment is multimodal in nature, ranging from conservative treatment to open surgical repair. The last one is associated, although in a small proportion, to complications, such as infections, hematomas and even death, besides the risks of the anesthetic procedure itself. The authors of the present article present a case report of the successful treatment of a depressed skull fracture in a newborn patient, using the vacuum-suction technique. The use of vacuum-suction may be beneficial for the pediatric patients, as it is a quick, non-invasive procedure, without the need for general anesthesia.

The Incidence of Depressed Skull Fractures Due to the Use of Pin-Type Head Frame Systems in the Adult Population: 10-year Experience of a Single Neurosurgical Center.

OBJECTIVE: Pin-type head frame systems have become a worldwide standard procedure, but they can cause some complications on rare occasions. This study aimed to examine the incidence and associated risk factors of depressed skull fracture and related intracranial hematoma (DSFH) due to the use of head frames in our institute over the past 10 years. METHODS: This study included 1749 patients who underwent neurosurgical surgeries using pin-type head frames, including the Mayfield (Integra NeuroSciences, Plainsboro, NJ) skull clamp (721 cases) and the Sugita (Mizuho Ikakogyo Co., Ltd., Tokyo, Japan) head frame (1028 cases). We retrospectively reviewed hospital records of our institute to identify cases of DSFH, and documented the type of head frame used, as well as patient characteristics. RESULTS: The incidence of DSFH was 0.29% (5 of 1749 cases). All 5 cases had an associated epidural hematoma, with a single case having an additional dural laceration (without subdural damage). All perforation sites, located at the parietal bone near the pterion, occurred by the unilateral horizontal screw of the Sugita head frame. None of the patients experienced postoperative neurological decline. CONCLUSIONS: Even in the adult population, the DSFH by the pin-type head frame can occur infrequently. Based on our results, we recommend that the following factors should be considered when the pin-type head frame is used for neurosurgical procedures: location of pin application, thickness and fragility of the skull, and adequate control of compressive forces exerted by the head frame.

Surgical Treatment of a Child With Acute Cortical Blindness Caused by Depressed Skull Fracture.

Linear skull fractures are relatively common in children, however, it is rarer to see depressed fractures. This report details the case of a 7-year-old boy who was admitted to the emergency department with complete blindness after having experienced an in-car traffic accident. Brain tomography of the patient showed that a large, island-shaped piece of occipital bone was depressed on the visual cortex and superior sagittal sinus in the midline. Presentation of complete loss of vision after an isolated head trauma is very rare, and there are no similar cases in existing literature. The limits of surgical indications for depressed skull fractures are well established in neurosurgical practice. Surgical intervention should be performed immediately, especially in cases where neurological changes develop in the earliest stages after a trauma. The patient underwent emergency surgery to correct the blindness without affecting the vascular neighborhood. The depressed cranium was raised to its original position. The blindness had completely resolved shortly after the patient woke up during the postoperative period.

Delayed Neurological Deterioration after Depressed Fracture over Superior Sagittal Sinus: Our Experience with 13 Patients.

OBJECTIVE: To present our experience in the diagnosis and management protocol of 13 patients with a depressed skull fracture over the superior sagittal sinus (SSS) who developed delayed neurologic deterioration. PATIENTS AND METHODS: This retrospective study was conducted in the Neurosurgical Department, Assiut University Hospitals, between May 2012 and May 2017. All patients with a depressed skull fracture over the SSS were reviewed. Only those patients who were neurologically intact after trauma but suffered delayed neurologic deterioration were included in this study. Preoperative characteristics of age, sex, cause of trauma, type and site of the depressed skull fracture, and clinical presentation were reviewed and evaluated. Neuroimaging including brain computed tomography and computed tomography venography were evaluated. RESULTS: Of 612 patients with depressed skull fractures admitted to our department, 63 had the fracture segment on the SSS. Thirteen patients, nine males and four females, met the inclusion criteria (age range: 5-42 years). The most common cause of trauma was assault from others (seven patients). Eight patients had a compound depressed fracture; the other five fractures were simple. Interval between trauma and neurologic deterioration ranged between 4 days and 3 weeks. Clinical deterioration included decrease of consciousness, headache, blurred vision, and repeated vomiting. Deterioration of consciousness was seen in four patients. Eight patients had sixth cranial nerve palsy. Visual deterioration was seen in four patients. All the included patients were operated on for elevation of the depressed segment. Eleven patients improved; two patients who presented initially with visual deterioration did not improve. Their visual deterioration persisted after surgery. For both these patients, lumbar puncture revealed high cerebrospinal fluid (CSF) pressure. Clinical improvement followed the insertion of a thecoperitoneal shunt. CONCLUSION: Increased intracranial pressure (ICP) may follow a depressed fracture over the SSS. It may occur immediately after trauma or later. Surgical decompression with elevation of the depressed segment is indicated. Persistence of manifestations of raised ICP despite elevation of the depressed segment indicates the occurrence of an SSS thrombosis. CSF pressure should be measured to confirm the diagnosis and consider a thecoperitoneal shunt.

Treatment of Traumatic Depressed Compound Skull Fractures.

BACKGROUND: A skull fracture widely occurs in patients with traumatic brain injury, leading to intracranial hematoma, brain contusion, and intracranial infection. It also influences the prognosis and death of patients. This study aimed to discuss cases of patients with comminuted skull fractures. METHODS: From October 2015 to December 2018, 38 patients with comminuted skull fractures were admitted to the hospital. All patients underwent three-dimensional reconstruction of computed tomography scan images. Digital subtraction angiography or magnetic resonance venography was performed to find out the venous sinus. The clinical findings of the patients were significant regarding gender, age, injury mechanism, location, admission Glasgow Coma Scale (GCS), combined epidural, subdural, cerebral contusion, intracranial pneumatosis, maximum depth of depression, admission to surgery, dural tear, post-operative cerebrospinal fluid leakage, post-operative infection, and Glasgow Outcome Scale (GOS) 3 months after surgery. RESULTS: The incidence of traffic accidents, fall from a height, railway accidents, fall of an object, and chop injury was 60.5%, 18.4%, 13.2%, 5.3%, and 2.6%, respectively. Intra-operative dural trar negatively correlated with epidural hematoma, cerebral contusion, and subdural hematoma. Also, post-operative infection negatively correlated with intracranial pneumatosis, depth of fracture depression, and pre-operative cerebrospinal fluid leakage. No correlation was found between contusion, subdural hematoma, intracranial pneumatosis, depth of fracture depression, and post-operative infection. The GOS score positively correlated with age, pre-operative cerebrospinal fluid leakage, and admission GCS score. CONCLUSIONS: A perfect pre-operative examination is a key to successful surgery. Further studies should be conducted to find out more effective treatments for traumatic comminuted skull fractures.

Depressed Skull Fractures Overlying Dural Venous Sinuses: Management Modalities and Review of Literature.

AIM: To characterize the sociodemographic, clinical and radiological findings of patients with depressed skull fractures overlying cranial dural sinuses that we have faced in our institute. In addition, to explore the indications and choices for the surgical and nonsurgical management of such cases, and assess outcomes in these two treatment groups. MATERIAL AND METHODS: We prospectively followed up a cohort of 34 patients with fractures over dural venous sinuses from January 2013 to December 2017. Twelve (35.1%) were simple depressed fractures (SDFs) and 22 (64.7%) were compound depressed fractures (CDFs). Eighteen patients (52.9%) were treated surgically, and 16 (47.1%) were treated conservatively. RESULTS: The mean age was 20.8 years. Thirty-two of the patients were males (94.12%). The mean time from trauma until hospital arrival was 3.8 hours, and the mean admission Glasgow Coma Score (GCS) was 13.7. Direct trauma was the most common mode of injury. Funduscopy was performed in 16 patients (47.1%), and magnetic resonance venography (MRV) in four patients (11.8%). Twenty-four patients (70.59%) had the fracture overlying the superior sagittal sinus (SSS). The mean length of hospital stay was five days, and the mean follow-up duration was 6.8 months. Twenty-eight patients (82.35%) had a good recovery. CONCLUSION: The majority of SDFs and some CDFs overlying dural sinuses can be managed safely without major surgical intervention. Conservation should be favored when the sinus is patent, dura intact, and bone displacement is insignificant in neurologically intact patients with an apparently clean wound. Otherwise, surgery should be considered. We also propose including a funduscopic examination and venogram as parts of the initial trauma work-up for these patients.

Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study.

STUDY OBJECTIVE: Existing clinical decision rules guide management for head-injured children presenting 24 hours or sooner after injury, even though some may present greater than 24 hours afterward. We seek to determine the prevalence of traumatic brain injuries for patients presenting to emergency departments greater than 24 hours after injury and identify symptoms and signs to guide management. METHODS: This was a planned secondary analysis of the Australasian Paediatric Head Injury Rule Study, concentrating on first presentations greater than 24 hours after injury, with Glasgow Coma Scale scores 14 and 15. We sought associations with predictors of traumatic brain injury on computed tomography (CT) and clinically important traumatic brain injury. RESULTS: Of 19,765 eligible children, 981 (5.0%) presented greater than 24 hours after injury, and 465 injuries (48.5%) resulted from falls less than 1 m and 37 (3.8%) involved traffic incidents. Features associated significantly with presenting greater than 24 hours after injury in comparison with presenting within 24 hours were nonfrontal scalp hematoma (20.8% versus 18.1%), headache (31.6% versus 19.9%), vomiting (30.0% versus 16.3%), and assault with nonaccidental injury concerns (1.4% versus 0.4%). Traumatic brain injury on CT occurred in 37 patients (3.8%), including suspicion of depressed skull fracture (8 [0.8%]) and intracranial hemorrhage (31 [3.8%]). Clinically important traumatic brain injury occurred in 8 patients (0.8%), with 2 (0.2%) requiring neurosurgery, with no deaths. Suspicion of depressed skull fracture was associated with traumatic brain injury on CT consistently, with the only other significant factor being nonfrontal scalp hematoma (odds ratio 19.0; 95% confidence interval 8.2 to 43.9). Clinically important traumatic brain injury was also associated with nonfrontal scalp hematoma (odds ratio 11.7; 95% confidence interval 2.4 to 58.6) and suspicion of depressed fracture (odds ratio 19.7; 95% confidence interval 2.1 to 182.1). CONCLUSION: Delayed presentation after head injury, although infrequent, is significantly associated with traumatic brain injury. Evaluation of delayed presentations must consider identified factors associated with this increased risk.

Outcome of Primary Bone Fragment Replacement in Pediatric Patients with Depressed Skull Fracture.

OBJECTIVE: To evaluate pediatric patients who were operated with the diagnosis of depressed skull fracture. METHODS: The records of pediatric patients who presented with traumatic head injury to multicenter neurosurgery clinics between 2002 and 2018 and who were operated with a diagnosis of depressed skull fracture were retrospectively reviewed. All of the patients underwent primary bone fragment replacement operation, and the patients' own bone flaps were used to repair depressed skull fractures in all of them. RESULTS: A total of 78 patients were included in the study. Of the study group, 20 patients presented with mild head injury, 37 had moderate head injury, and 21 had severe head injury. Dural injury was present in 67 patients (86%) and the dura was intact in 11 patients (14%). After surgery, 63 patients (81%) had good outcome, 8 patients (10%) had moderate disability, and 5 patients (6.5%) had severe disability. Two patients with multiple accompanying cranial pathologies died and the mortality rate was 2.5%. Infection was detected in only 2 of the 78 patients who were treated within the first 72 h after trauma. One of them had meningitis and the other skin infection. Both patients were treated with appropriate antibiotherapy. None of the patients in the study group had an infection involving the bone, such as osteomyelitis, or the tissues under the bone, such as subdural-epidu-ral empyema or abscess. None of the patients required reoperation and removal of the bone. CONCLUSION: In the present study, as the pathologies accompanying the depressed skull fractures of the patients increased, Glasgow Coma Scale scores at arrival and Glasgow Outcome Scale scores at discharge decreased. Regardless of whether the depressed fracture is simple or compound, primary bone fragment replacement with appropriate decontamination of the fractured bone and operation area via single-session intervention gives good results. It is important to perform the surgery as soon as possible to reduce the risk of contamination. Primary bone fragment replacement seems to be an appropriate treatment option for depressed skull fractures.

Newborn with a depression to her skull.

A 9 week-old female, born via normal spontaneous vaginal delivery at 40 weeks, presented to the emergency department for a depression to her left skull, first noticed 3 three weeks prior. Ping Pong Fractures should be recognized and appropriately treated by an emergency physician.

Localization of the Maxillary Ostium in Relation to the Reduction of Depressed Nasomaxillary Fractures.

The aim of this study was to elucidate the precise location of the maxillary ostium using computed tomography for the reduction of depressed nasomaxillary fractures.Computed tomography images (61 males, 42 females; age range, 3-97 years) were analyzed. Coronal sections were cut every 3 mm.The primary maxillary ostium (PMO) was located 24.7% ±â€Š3.9% of bizygomatic distance (BZD) lateral to septum. The horizontal distance of the PMO significantly increased with age (P = 0.032). The PMO was located 53.3% ±â€Š8.0% of nasal length (NL) above superior surface of the palatal bone (SP). The vertical-to-horizontal ratio of the PMO decreased with age (P = 0.013). The PMO was located 30.3 ±â€Š4.3 mm posterior to the tip of nasal bone. The PMO was located 24.6 ±â€Š4.8 mm posterior to the anterior nasal spine (ANS). The ANS-PMO distance significantly increased with age (P = 0.027). The hiatus semilunaris (HS) was located 11.9% ±â€Š3.2% of BZD lateral to septum. The HS was located 62.4% ±â€Š10.3% of NL above SP. The vertical distance of the HS significantly decreased with age (P = 0.019). The accessory maxillary ostium (AMO) was located 14.9% ±â€Š2.8% of BZD lateral to septum. The horizontal distance of the AMO significantly increased with age (P = 0.027). The AMO was located 44.8% ±â€Š6.9% of NL above SP. The vertical distance of the AMO significantly decreased with age (P < 0.001). The vertical-to-horizontal ratio of the AMO decreased with age (P < 0.001).The distances of the ostium from surgical landmarks measured in this study might be helpful when inserting a small curved elevator into the maxillary ostium in the reduction of medial maxillary fractures.