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PubMed2001

Facial fractures in children.

OBJECTIVE: To determine the pattern of injury of facial fractures in children, the relative contribution of plain radiography and CT scanning in the diagnosis of these injuries, and factors leading to delayed diagnosis. DESIGN: Retrospective case note review. PARTICIPANTS: All children with facial fractures identified using the trauma and medical record databases at our institution. RESULTS: Forty-six children with 59 facial fractures presented over a 4-year, 2-month period from November 1995 to December 1999. The median age was 10 years, with a range from 1 to 14. There was a 2-to-1 male-to-female sex ratio. A motor vehicle accident (MVA) involving a child as passenger, pedestrian, or cyclist accounted for 63% of cases. In seven of these, the child was either a front seat passenger or inappropriately restrained for their age and size. In all but one case, the presence of a fracture was associated with an overlying laceration, abrasion, or significant soft tissue edema. Initial examination and plain radiologic assessment by a pediatric clinician led to diagnostic delay in nine children. Facial CT was performed in 38 children, and all results were positive. Twenty-six patients required operative intervention for their facial fracture. Associated injuries, particularly of the head and limbs, were present in all but six patients. CONCLUSIONS: Facial fractures were uncommon overall but occurred more frequently in children with major trauma. Plain facial radiographs provided limited additional diagnostic information to careful clinical examination and often fail to detect or clearly define a facial fracture in children. In the correct clinical setting, a facial CT scan allows accurate diagnosis of the injury and can reveal previously unsuspected additional fractures.

Accidents, Traffic↗
PubMed1986

Osteogenic sarcoma of the mandible and maxilla.

Our early aggressive management of osteogenic sarcoma of the facial skeleton in two patients included the use of radical surgery, irradiation, and chemotherapy. One patient died after two years, but the other patient is alive and free of disease after five years. Despite a better prognosis for osteogenic sarcoma of the facial bones than for osteogenic sarcoma of the long bones, it remains a highly lethal disease with a high local recurrence rate.

Adult↗
PubMed2004

Predicting the result of our X-rays, a way to identify overuse? the Ulster Hospital Dundonald.

OBJECTIVE: The objectives of the study were to identify areas of the unnecessary use of diagnostic plain X-rays in the emergency department. Requests for inappropriate plain X-ray investigations have resource, radiation and overcrowding implications for the emergency department. METHODS: The junior doctor or nurse practitioner treating patients attending the emergency department requiring X-ray completed a proforma prospectively. Questions included the type of X-ray, predicted result of the X-ray and observed result of X-ray. RESULTS: A total of 226 out of 280 X-rays (81%) were accurately predicted, 94 X-rays (34%) were abnormal. Facial bones (100%) and skull (79%) were most commonly X-rayed when the result was predicted accurately to be normal. The threshold for X-raying abdomen, kidney, ureter and bladder and lumbar spine was low with normal accurate predictions of 67, 75 and 75%, respectively. Normal knee and foot X-rays were predicted accurately in 61 and 60% of cases, respectively, with a yield of 28 and 13%, respectively. CONCLUSION: The training of emergency medicine staff should include education about clinical indications from guidelines and recommendations about X-ray use, information on the dose of radiation exposure, implications of resources and overcrowding of departments.

Emergency Medicine↗
PubMed2003

The safe face lift with bony anatomic landmarks to elevate the SMAS.

The risk for facial nerve injury has been reported to be increased with the inclusion of superficial musculoaponeurotic system (SMAS) elevation as compared with a skin-only face lift. The facial nerve courses through the parotid gland. The SMAS is elevated superficial to the parotid gland. However, in elevating the SMAS anterior to the parotid gland, the facial nerve is at risk of injury where its branches emerge from the anterior edge of the parotid gland. The purpose of this study was to identify bony anatomic landmarks to predict the location of the anterior edge of the parotid gland to avoid injury to the facial nerve branches as they exit the parotid gland. The authors dissected 20 cadaver face halves to determine bony landmarks-the masseteric tuberosity and the inferior lateral orbital rim-to predict the location of the anterior parotid edge. Then they measured the anterior edge of the parotid gland in relation to the vector formed between these two bony landmarks. They identified and measured the most anterior portion of the parotid gland in relation to this vector. Then the most posterior aspect of the parotid gland in relation to this vector was measured. In the 20 dissections, the authors found the most anterior portion of the parotid gland to be 2.7 +/- 1.0 mm anterior to the vector from the inferior lateral orbital rim to the masseteric tuberosity. The most posterior part of the anterior edge of the parotid gland in relation to this vector was found to be 1.0 +/- 1.5 mm posterior to this vector. The parotid gland measured an average of 38.8 +/- 3.5 mm in width from the tragus to the anterior parotid edge. In elevating the SMAS with a face lift, the facial nerve branches can be predicted to exit the anterior edge of the parotid gland, which can be located 38.8 mm anterior to the tragus and near the vector from the inferior lateral orbital wall to the masseteric tuberosity.

Cephalometry↗
PubMed2004

Subperiosteal midface lifting: a simplified approach.

A simplified approach to subperiosteal midface lifting with suspension is described, which has been performed on 75 patients since 1986. In comparison with standard facelifting, this technique results in long-lasting vertical resuspension of ptotic midfacial tissues. To date there has been a high rate of patient satisfaction with no cases of nerve injury or hematoma. There is a rare incidence of minor complications.

Adult↗
PubMed2004

Cranial mechanics and feeding in Tyrannosaurus rex.

It has been suggested that the large theropod dinosaur Tyrannosaurus rex was capable of producing extremely powerful bite forces and resisting multi-directional loading generated during feeding. Contrary to this suggestion is the observation that the cranium is composed of often loosely articulated facial bones, although these bones may have performed a shock-absorption role. The structural analysis technique finite element analysis (FEA) is employed here to investigate the functional morphology and cranial mechanics of the T. rex skull. In particular, I test whether the skull is optimized for the resistance of large bi-directional feeding loads, whether mobile joints are adapted for the localized resistance of feeding-induced stress and strain, and whether mobile joints act to weaken or strengthen the skull overall. The results demonstrate that the cranium is equally adapted to resist biting or tearing forces and therefore the 'puncture-pull' feeding hypothesis is well supported. Finite-element-generated stress-strain patterns are consistent with T. rex cranial morphology: the maxilla-jugal suture provides a tensile shock-absorbing function that reduces localized tension yet 'weakens' the skull overall. Furthermore, peak compressive and shear stresses localize in the nasals rather than the fronto-parietal region as seen in Allosaurus, offering a reason why robusticity is commonplace in tyrannosaurid nasals.

Animals↗
PubMed1996

A study of maxillofacial injuries in the elderly resulting from falls.

Falls are a major problem for the elderly, both in terms of the injuries sustained and the consequent loss of confidence and independence. Many studies, both prospective and retrospective, have investigated the possible causes and the resulting injuries following falls. However, no specific consideration appears to have been given to maxillofacial injuries. This survey examines the incidence of such injuries, over a three year period, in elderly patients presenting at an Accident and Emergency Department, and reviews the causes. Recognition of old age abuse is an essential aspect of the assessment of injuries in this group of patients.

Accidental Falls↗
PubMed1986

The Cowden syndrome: a clinical and genetic study in 21 patients.

An analysis of the findings in 21 patients with the Cowden syndrome or the multiple hamartoma syndrome is presented. The Cowden syndrome is a cancer-associated genodermatosis with characteristic mucocutaneous findings and a wide array of associated abnormalities including a high incidence of breast cancer in female patients. Genetic studies confirmed autosomal dominant inheritance with a high penetrance in both sexes and moderate interfamilial and intrafamilial differences in the expressivity of a number of symptoms. Familial occurrence was present in 4 of the 7 families. There was a strong predominance of female patients (6:1), which may be fortuitous. Mucocutaneous changes were the most constant (100% incidence) and characteristic findings; they almost invariably became manifest in the second decade. Four of our 18 female patients (22%) were treated for breast cancer, a lower incidence than reported previously. No increased incidence of other types of malignancies was found. Craniomegaly (high head circumference) was found to be the most common extracutaneous manifestation (80% incidence); craniomegaly appears to be an important early marker. We also found high incidences of gastrointestinal polyps (approximately 60%) and cutaneous fibromas (76%), while the incidence of thyroid abnormalities, thus far regarded as the most common extracutaneous finding, was similar to that reported previously (62%). G-banded karyotype and preliminary DNA-repair studies revealed no clear abnormalities. No linkage with the loci of HLA, and immunoglobulin haplotypes was found.

Abnormalities, Multiple↗
PubMed1997

A new multiple malformation syndrome of Müllerian dysgenesis and conductive hearing loss with facial hypoplasia, bilateral forearm deformity, brachydactyly, spinal stenosis and scoliosis.

Multiple congenital malformations in a young girl with bilateral conductive hearing loss are described. Facial dysmorphic features include prominent supraorbital ridges, facial hypoplasia, facial asymmetry, downward-slanting palpebral fissures, high prominent nasal bridge with bifid nasal tip and a small lower jaw, and hypoplastic ear lobules with bilaterally narrow and oblique external auditory canals. Recognisable skeletal abnormalities include hypoplastic facial bones, hypoplastic clavicles, narrow and anteriorly sloping shoulders, bowing of both forearm bones, brachydactyly due to short metacarpals and hypoplastic terminal phalanges, thoracolumbar kyphoscoliosis, narrow transverse measurements of most vertebrae with prominent coccyx, spinal canal narrowing, hypoplasia of lower ilia, medially bowed femora, tibiae and fibulae and brachysyndactyly of the second, third and fourth toes bilaterally. Gynaecological evaluation revealed abnormalities of the Mullerian duct structures: urogenital sinus, a vestigial uterus, a posteriorly placed small but patent vagina and a septum at the vaginal introitus. The pattern of MCA probably refers to a new syndrome within the "community of syndromes" involving anomalies of the Mullerian duct structures, limbs, spine and external ears.

Abnormalities, Multiple↗
PubMed2006

Orbital rhabdomyosarcoma: multidisciplinary treatment experience.

Orbital rhabdomyosarcoma (RMS) accounts for 10% of childhood RMS and has a relatively good prognosis of up to 85% 5-year survival. Improved survival has led to increased interest in late effects of treatment. The objective of this study was to review the results of treating orbital RMS with multidisciplinary treatment at Women's and Children's Hospital and Royal Adelaide Hospital with emphasis on late effects of treatment. A retrospective review was carried out of all patients with orbital RMS treated with multidisciplinary treatment including radiation therapy and chemotherapy in the two institutions between 1982 and 2002. A total of five patients (age range 5.5-12 years) satisfied the eligibility requirements. Late effects were significant and included facial bone hypoplasia, cataract formation and growth hormone deficiency. Overall survival was 80% (4/5) with mean follow up of 8 years (range 3-13 years). Given the high cure rates achieved, future treatments must aim to maintain the good results but to reduce the high incidence of late effects of treatment. Standardised rating of late toxicity, long-term follow-up clinics, and implementation of modern radiation techniques (3-D conformal radiotherapy, intensity modulated radiotherapy, proton therapy) for patients with orbital RMS are important to improving outcome.

Child↗
PubMed1992

An autopsy case of invasive pituitary adenoma (prolactinoma) with rapid fatal clinical course due to streptococcal meningitis.

A 44-year-old male suffered epistaxis and headache of sudden onset and was diagnosed as having suppurative meningitis due to streptococci. Four days after the onset of symptoms, he died despite treatment with antibiotics. Destruction and ballooning of the sella turcica was revealed by a plain head X-ray examination during the clinical course. At autopsy, a massive tumorous lesion extended from the ballooned sella turcica to the paranasal cavities, nasopharynx and facial bone, and this had resulted in suppurative meningitis. The tumor was also disseminated to the basal skull. The tumor cells possessed prominent nuclear atypia and were immunohistochemically positive for prolactin. This was diagnosed as a case of pituitary adenoma with markedly invasive pathological findings and a rapid and fatal clinical course.

Adenoma↗
PubMed1986

Multiple hamartomas associated with intracranial malformation.

We examined a newborn infant with multiple hamartomas, including an epidermal nevus syndrome and a giant pigmented congenital nevocellular nevus, associated with other structural developmental abnormalities such as nevus flammeus, vascular malformation, cutis aplasia congenita of the scalp, cartilage hamartoma, and a lipodermoid of the conjunctiva. This child had a significant brain malformation, diagnosed by sonography and computerized tomography, consisting of a significant enlargement of the left hemisphere not associated with asymmetry of the skull or facial bones. We suggest a careful investigation of the intracranial structures by computerized tomography and/or ultrasonography in case of either extensive linear nevus sebaceous sequence and/or giant pigmented nevocellular nevus.

Adult↗
PubMed1996

The frequency of unsuspected minor illness or injury in intoxicated patients.

OBJECTIVE: To determine the frequency of unsuspected minor illness or injury in a group of patients frequently seen in the ED for acute intoxication. METHODS: The medical records of the 20 patients seen most frequently in the ED for acute intoxication in 1993 were reviewed for the number of ED visits for intoxication, the number of associated documented episodes of minor trauma or illness, the extent of ED workup of discovered illness or injury, and patient disposition from the ED. RESULTS: The 20 study patients were evaluated in the ED 1,858 times in 1993 for acute intoxication, a mean of 92.5 visits/patient (+/- 26.6). The most frequent injury was minor trauma above the neck, occurring a mean of 9 times (+/- 3.6) in each of the study patients during 1993. Evaluation included repeated neurologic examinations and frequent radiography of the cervical spine (n = 80), skull (n = 5), facial bones (n = 6), and mandible (n = 5). A limited number of head CT scans also were done (n = 8). The most frequent minor illnesses were gastritis (n = 7), managed with hydration, and mild hypothermia (n = 6), managed with passive rewarming. CONCLUSIONS: The incidence of unsuspected minor illness or injury in this patient group was substantial. While most unsuspected medical problems had little clinical significance, some were potentially dangerous, and some necessitated hospitalization (e.g., hypothermia, hematemesis, and respiratory depression).

Acute Disease↗
PubMed2006

Sex determination using nonmetric characteristics of the mandible in Koreans.

The mandible is the largest and hardest facial bone and retains its shape better than other bones in the forensic and physical anthropologic field. The mandible can be used to distinguish among ethnic groups and between sexes. We examined the morphological characteristics of the mandibles of 102 Koreans of either sex. Of 13 nonmetric items of the mandible, the characteristic that best allowed the sexes to be distinguished was the contour of the lower border of the mandible: rocker-shaped mandibles predominated in males (68.1%), whereas most females (84.6%) exhibited a straight mandible. In addition, the mental region was shaped differently between the sexes: the shape of the chin in most males was generally bilobate or square (91.7%), whereas the chin in females was either square (45.5%) or pointed (54.5%). In this study, the positive predict values of male and female were 92.5% and 73.7%, respectively. Therefore, the nonmetric method used to analyze the mandible in this study can be used for sex discrimination.

Adolescent↗