MANDIBULO- Bert De Foer A. Bernaerts, E. Loney +, J. Van Dinther, Th. Somers, E. Offeciers, A. Zarowski, J.W.Casselman / /* DEPARTMENT OF RADIOLOGY, GZA HOSPITALS SINT-AUGUSTINUS, ANTWERP, BELGIUM DEPARTMENT OF RADIOLOGY, AZ SINT-JAN AV, BRUGES, BELGIUM + COUNTY DURHAM AND DARLINGTON NHS FT MANDIBULO- DISCLOSURE OF CONFLICT OF INTEREST There are no potential conflicts of interest, relevant relationships or financial interests to report regarding this presentation. EUROPEAN INSTITUTE of ORL, GZA HOSPITALS SINT-AUGUSTINUS, ANTWERP, BELGIUM * UNIVERSITY OF GHENT, GHENT, BELGIUM EUROPEAN COURSE IN NEURORADIOLOGY DIAGNOSTIC AND INTERVENTIONAL 14 TH CYCLE, MODULE 4 TRAUMA, INFECTION AND DEGENERATIVE DISEASE 6 th -10 th MAY 2018 ANTWERP BELGIUM MANDIBULO- MANDIBULO- I. MANDIBULO- I. MANDIBULO- II. SKULL BASE / TEMPORAL BONE TRAUMA II. SKULL BASE / TEMPORAL BONE TRAUMA III. THE BEST OF THE REST III. THE BEST OF THE REST MANDIBULO- MANDIBULO- NASAL BONES : 30 G MANDIBULAR GENU: 40 G ZYGOMA: 50 G LOW G MANDIBULAR RAMI: 70 G Low G High G ETMOID: 80 G ALVEOLAR MARGINS: 100 G FRONTAL BONES: 200 G HIGH G Minor Injury 30% 32% Major Injury 21% 51% Mortality 2% 15% Maxillofacial Trauma. Luce et al Curr Probl Surg. 1984;21(2):1-68
MANDIBULO- MODALITIES CT (and not CBCT SOFT TISSUE VISUALISATION!!) MOST USEFUL MODALITY IN : FAST + COMPLETE SUB-mm HELICAL NON CONTRAST BONE AND SOFT TISSUE SETTING MPR and 3D RECONSTRUCTION PLAIN FILMS EVALUATION OF SIMPLE FRACTURES: NASAL BONES POOR IN COMPLEX INJURIES MANDIBULO- MODALITIES MRI NOT USED IN THE ACUTE SETTING COMPLEMENTARY IN UNEXPLAINED POST-TRAUMATIC CRANIAL NERVE DEFICITS EVALUATION OF INTRACRANIAL INJURY AND DIFFUSE AXONAL INJURIES MANDIBULO- THE PRINCIPLE OF FACIAL BUTTRESSES MANDIBULO- THE PRINCIPLE OF FACIAL BUTTRESSES: WHY DO BUTTRESSES MATTER? ALL LINKED DIRECTLY OR VIA ANOTHER BUTTRESS TO THE SKULL BASE Transverse Buttresses TRANSVERSE REDUCTION RESTORES FACIAL PROFILE VERTICAL REDUCTION RESTORES FACIAL HEIGHT REDUCTION ESTABLISHES FUNCTIONAL SUPPORT FOR TEETH AND GLOBES Vertical Buttresses MANDIBULO- WHERE DO WE START?? MANDIBULO- WHERE DO WE START?? STEP 1 : ARE THE PTERYGOID PLATES INVOLVED?
MANDIBULO- WHERE ARE THE PTERYGOID PLATES?? MANDIBULO- THE LE FORT FRACTURES R NAMED AFTER A FRENCH SURGEON: RENE LE FORT (1869-1951) THREE DISTINCT INCT SUBTYPES S NO PTERYGOID PLATE FRACTURE = NO LE FORT FRACTURE MULTIPLE LE FORT FRACTURE PATTERNS CAN OCCUR AT THE SAME TIME DIFFERENT COMBINATIONS IONS CAN OCCUR ON THE TWO SIDES OF THE FACE MANDIBULO- MANDIBULO- THE LE FORT FRACTURES TYPE 1 : FLOATING TEETH / PALATE TYPE 2: FLOATING MAXILLA TYPE 3: FLOATING FACE LE FORT TYPE 1 : FLOATING TEETH / PALATE MANDIBULO- MANDIBULO- Male, 57-years-old Drunk, felt down when trying to get on his bicycle, leaving the pub to go home. LE FORT TYPE 2 : FLOATING MAXILLA PYRAMIDAL FRACTURE
MANDIBULO- MANDIBULO- Male, 42-years-old Construction worker, Fall through a roof, 5 meters deep, face down. LE FORT TYPE 3 : FLOATING FACE MANDIBULO- MANDIBULO- STEP 2 : MEDIAL OR LATERAL BUTTRESS? NASO-ORBITO-ETHMOIDAL COMPLEX (NOE) OR ZYGOMATICOMAXILLARY COMPLEX (ZMC) NASO-ORBITO-ETHMOIDAL FRACTURE MANDIBULO- NASO-ORBITO-ETHMOIDAL FRACTURE CENTRAL UPPER MIDFACE FRACTURE INVOLVING NOSE, ETHMOIDS AND MEDIAL ORBITAL WALLS. WHAT TO REPORT ON CT DEGREE OF COMMINUTION OF MEDIAL MAXILLARY BUTTRESS ESPECIALLY THE LACRIMAL FOSSA DISTANCE BETWEEN THE LACRIMAL FOSSAE DISRUPTION OF NASOFRONTAL DUCTS (PREDISPOSES TO FRONTAL MUCOCELES) EVENTUAL FRONTAL LOBE CONTUSION MANDIBULO- NASO-ORBITO-ETHMOIDAL FRACTURE : COMPLICATIONS TELECANTHUS - HYPERTELORISM ENOPHTHALMOS MEDIAL CANTHAL ABNORMALITIES FORESHORTENED NOSE GLOBE DISPLACEMENT NASAL AIRWAY OBSTRUCTION LACRIMAL OBSTRUCTION
LO LO Male, 25-years-old Ô Stuck with the wheels of his bicycle in a tram track, lost his balance, felt on the right side of his face. Ô Ï Ð II I III Ï I LOFACIAL TRAUMA III II LO Ð Ô Ô Ò Ó Î Î Î Ï Ó ZYGOMATICOMAXILLARY COMPLEX FRACTURE (TRIPOD) FRACTURE I II Ð III LO LO ZYGOMATICOMAXILLARY COMPLEX (ZMC) FRACTURES PREVIOUSLY CALLED TRIMALAR OR TRIPOD FRACTURE FRACTURE COMPLEX WITH FRACTURE LINES INVOLVING ZYGOMATIC ARCH, LATERAL ORBITAL WALL, ANTERIOR AND LATERAL WALLS OF MAXILLARY SINUS AND ORBITAL FLOOR INFERIOR ORBITAL NERVE OFTEN INVOLVED RELATION TO CORONOID PROCESS OF MANDIBLE IS TO BE REPORTED
MANDIBULO- MANDIBULO- MANDIBULAR FRACTURES STUDIES VARY FROM 36-70% OF ALL MAXILLO-FACIAL FRACTURES. M > F STEP 3 : IF NONE OF THE FORMER IS THIS AN ISOLATED FRACTURE? NUMBER OF FRACTURES PER PATIENT 1 FRACTURE: 50 % 2 FRACTURES: 40% >2 FRACTURES: 10% 15% HAVE ANOTHER FACIAL FRACTURE RELATIONSHIP TO THE MANDIBULAR CANAL AND NERVE A MANDIBULE USUALLY NEVER FRACTURES ON ONE PLACE! MANDIBULO- MANDIBULO- Male, 23-years-old During sports, direct fall on his chin MANDIBULO- MANDIBULO- TYPES Symphyseal Parasymphyseal Body Ramus Angle Condylar Coronoid Alveolar DISPLACEMENT DUE TO MUSCLE PULL OF MEDIAL AND LATERAL PTERYGOID
LO LO 38-year old male Shot by his neighbour in the face after having had a discussion on loud music during a barbecue party. LOFACIAL TRAUMA FACIAL TRAU T RAUM UMA LO 38-year old male Rollover with his mountain bike. Hit the steering wheel with his teeth. LO LO
MANDIBULO- DENTOALVEOLAR FRACTURES: ELLIS AND DAVEY CLASSIFICATION I FRACTURE WITHIN ENAMEL II FRACTURE OF ENAMEL AND DENTINE III FRACTURE INVOLVING PULP IV TOOTH BECOMES NON-VITAL V AVULSION VI ROOT FRACTURE VII TOOTH DISPLACEMENT WITH NO FRACTURE IX CROWN EN MASSE FRACTURE AND AND ANN DISPLACEMENT X PRIMARY DENTITION INJURIES MANDIBULO- ORBITAL FRACTURES CAN BE ISOLATED OR ASSOCIATED WITH PREVIOUSLY DESCRIBED COMPLEXES. MANDIBULO- MANDIBULO- 2 young boys, involved in a fight. ORBITAL BLOW-OUT FRACTURE WITH DISPLACEMENT OF ORBITAL FLOOR AND DOWNWARDS HERNIATION OF ORBITAL FAT AND INFERIOR RECTUS MUSCLE MANDIBULO- MANDIBULO- ORBITAL FRACTURES CAN BE ISOLATED OR ASSOCIATED WITH PREVIOUSLY DESCRIBED COMPLEXES. BLOW-OUT FRACTURES LAMINA PAPYRACEA FRACTURES : MEDIAL RECTUS MUSCLE ORBITAL FLOOR FRACTURES : INFERIOR RECTUS MUSCLE FRACTURE OF LAMINA PAPYRACEA. NO ENTRAPMENT OF MEDIAL RECTUS MUSCLE
MANDIBULO- MANDIBULO- 3-year old female toddler fel from the stairs with a pencil in her mouth. The pencil perforated the hard palate. Parents withdraw the pencil before coming to the emergency department. MANDIBULO- MANDIBULO- Perforation of the hard palate and lamina papyracea with penetration of the orbital apex and optic nerve laceration and subsequent right-sided blindness. MANDIBULO- ORBITAL FRACTURES CAN BE ISOLATED OR ASSOCIATED WITH PREVIOUSLY DESCRIBED COMPLEXES. BLOW-OUT FRACTURES LAMINA PAPYRACEA FRACTURES : MEDIAL RECTUS MUSCLE ORBITAL FLOOR FRACTURES : INFERIOR RECTUS MUSCLE EXCLUDE FRACTURE FRAGMENT IMPINGEMENT LAMINA PAPYRACEA ON MEDIAL RECTAL MUSCLE ORBITAL APEX FRAGMENTS MANDIBULO- ORBITAL FRACTURES CAN BE ISOLATED OR ASSOCIATED WITH PREVIOUSLY DESCRIBED COMPLEXES. BLOW-OUT FRACTURES LAMINA PAPYRACEA FRACTURES : MEDIAL RECTUS MUSCLE ORBITAL FLOOR FRACTURES : INFERIOR RECTUS MUSCLE EXCLUDE FRACTURE FRAGMENT IMPINGEMENT LAMINA PAPYRACEA ON MEDIAL RECTAL MUSCLE ORBITAL APEX FRAGMENTS BEWARE OF DIPLOPIA
MANDIBULO- Lamina papyracea impinges on medial rectus. Muscle looks angulated. MANDIBULO- I. MANDIBULO- II. SKULL BASE / TEMPORAL BONE TRAUMA Medial wall fracture with enophthalmos. Medial rectus has lost flat profile and herniated into fracture site III. THE BEST OF THE REST MANDIBULO- MANDIBULO- 65-years-old female I. MANDIBULO- Fell down the stairs, drunk. II. SKULL BASE / TEMPORAL BONE TRAUMA III. THE BEST OF THE REST MANDIBULO- MANDIBULO- AX SE T1 - Gd AX RIGHT-SIDED CT TRANSVERSE FRACTURE LEFT-SIDED LONGITUDINAL FRACTURE WITH INVOLVEMENT OF THE OTIC CAPSULE AND INTRALABYRINTHINE AIR AX 3D FLAIR INTRALABYRINTHINE HEMORRAGHE ON THE RIGHT HEMOTYMPANUM ON THE LEFT
MANDIBULO- TRADITIONAL CLASSIFICATION : LONGITUDINAL T-BONE FRACTURES 80 90 % CAUSED BY A TEMPOROPARIETAL IMPACT FORCES RUN PARALLEL TO THE LONG AXIS OF THE TEMPORAL BONE OSSICULAR AND TYMPANIC MEMBRANE INJURY FREQUENT WITH CONDUCTIVE HEARING LOSS FACIAL PARALYSIS RARE MANDIBULO- TRANSVERSE TEMPORAL BONE FRACTURES 10 20 % CAUSED BY A FRONTAL/OCCIPITAL BLOW FORCES RUN PERPENDICULAR TO THE LONG AXIS OF THE TEMPORAL BONE LABYRINTH OFTEN INVOLVED WITH VERTIGO AND SNHL FACIAL PARALYSIS (40 50 %) OFTEN IMMEDIATE AND COMPLETE OSSICLES OFTEN SPARED (NO CHL) MANDIBULO- TRADITIONAL CLASSIFICATION : DRAWBACKS DOES NOT ADDRESS OBLIQUE or MIXED FRACTURES WHICH ARE MANDIBULO- 38-years-old male Left-sided deafness after a car crash. VERY FREQUENT DOES NOT CORRELATE WELL WITH CLINICAL OUTCOME / POTENTIAL COMPLICATIONS NEWER CLASSIFICATION: OTIC CAPSULE SPARING >< OTIC CAPSULE VIOLATING FRACTURES MANDIBULO- MANDIBULO- 42-years-old female LEFT-SIDED OTIC CAPSULE VIOLATING FRACTURE WITH AIR IN THE VESTIBULE Bilateral hearing loss after a car crash. Audiogram demonstrates bilateral conductive hearing loss.
MANDIBULO- MANDIBULO- 2 different patients with conductive hearing loss after a head trauma. BILATERAL AX CBCT OTIC CAPSULE SPARING FRACTURE WITH INCUDOMALLEAL SEPARATION MANDIBULO- DOUBLE OBLIQUE CT REFORMAT MANDIBULO- 47-years-old male Prior surgery with PORP placement on the left side. Severe left-sided conductive hearing loss after head trauma. DOUBLE OBLIQUE CBCT REFORMAT INCUDOSTAPEDIAL DISCONNECTION ON THE LEFT SIDE MANDIBULO- MANDIBULO- COMPLICATIONS OF TEMPORAL BONE TRAUMA: OSSICULAR INJURY OSSICULAR CHAIN DISRUPTION -> CONDUCTIVE HEARING LOSS REPEAT AUDIOGRAM AFTER RESORPTION OF BLOOD IN MIDDLE EAR PORP COR CBCT LUXATED OUT OF THE OVAL WINDOW STAPES LOST MALEUS ON TOP OF THE SCUTUM INCUS IN THE EAC DISLOCATION MUCH MORE FREQUENT THAN FRACTURE INCUDOSTAPEDIAL JOINT SEPARATION INCUDOMALLEAL JOINT SEPARATION INCUS DISLOCATION INCUDOMALLEAL COMPLEX DISLOCATION STAPEDIOVESTIBULAR DISLOCATION - > PERILYMPATHIC FISTULA
MANDIBULO- MANDIBULO- 25-years-old male Hearing loss after forcefull retraction of the index finger out of the external auditory canal. ISOLATED COR CBCT FRACTURE + SAG MIP OF MANUBRIUM MALEI REPAIRED USING BONECEMENT - OTOMIMIX MANDIBULO- COMPLICATIONS OF TEMPORAL BONE TRAUMA: OSSICULAR INJURY OSSICULAR CHAIN DISRUPTION -> CONDUCTIVE HEARING LOSS REPEAT AUDIOGRAM AFTER RESORPTION OF BLOOD IN MIDDLE EAR MANDIBULO- 26-years-old female Sudden onset of vertigo and conductive and sensorineural hearing loss after tympanic perforation with a scalp massage tool inserted by the patient s young child by accident DISLOCATION MUCH MORE FREQUENT THAN FRACTURE INCUDOSTAPEDIAL JOINT SEPARATION INCUDOMALLEAL JOINT SEPARATION INCUS DISLOCATION INCUDOMALLEAL COMPLEX DISLOCATION STAPEDIOVESTIBULAR DISLOCATION - > PERILYMPATHIC FISTULA ISOLATED OSSICULAR FRACTURE: MANUBRIUM MALEI MANDIBULO- MANDIBULO- + = AX CBCT
MANDIBULO- PROTRUSION IN THE VESTIBULE OF FOOTPLATE STAPES CAPITELLUM SURGERY WITH RETRACTION OF FOOTPLATE OUT OF VESTIBULE STAPES RECONSTRUCTION DISAPPEARANCE OF VERTIGO DURING THE DAYS FOLLOWING THE EVENT RECUPERATION OF 80% OF HEARING MANDIBULO- COMPLICATIONS OF TEMPORAL BONE TRAUMA: OSSICULAR INJURY OSSICULAR CHAIN DISRUPTION -> CONDUCTIVE HEARING LOSS REPEAT AUDIOGRAM AFTER RESORPTION OF BLOOD IN MIDDLE EAR DISLOCATION MUCH MORE FREQUENT THAN FRACTURE INCUDOSTAPEDIAL JOINT SEPARATION INCUDOMALLEAL JOINT SEPARATION INCUS DISLOCATION INCUDOMALLEAL COMPLEX DISLOCATION STAPEDIOVESTIBULAR DISLOCATION - > PERILYMPATHIC FISTULA ISOLATED OSSICULAR FRACTURE: MANUBRIUM MALEI FRACTURE OF STAPES: RARE PENETRATING INJURY MANDIBULO- MANDIBULO- 28-years-old male Severe conductive hearing loss after a head trauma with a left-sided temporal blow. AX CT + COR REFORMATS TEGMEN DEFECT WITH MENINGOCELE AND INCUDOMALLEAL SEPARATION MANDIBULO- COMPLICATIONS OF TEMPORAL BONE TRAUMA: CSF LEAKAGE 11 45 % / TEGMEN INVOLVEMENT OTIC CAPSULE VIOLATING INJURY: 4x MORE FREQUENT MANDIBULO- 44-years-old male Fall out of a tree. Hearing loss with also an immediate left-sided facial nerve palsy. USUALLY WITHIN A WEEK AFTER TRAUMA CLINICALLY: CSF OTORRHEA or CSF RHINORRHEA RISK OF MENINGITIS IF LEAKAGE PERSISTS MORE THAN 1 WEEK MENINGOCELE / ENCEFALOCELE : LATE COMPLICATION
MANDIBULO- MANDIBULO- COMPLICATIONS OF TEMPORAL BONE TRAUMA: FACIAL NERVE INJURY TRANSSECTION: IMMEDIATE FACIAL PARALYSIS DELAYED FACIAL NERVE INJURY: EDEMA, HEMATOMA, CONTUSION AX CBCT LOW GRADE / INCOMPLETE PARALYSIS: WAIT AND SEE HIGH GRADE / COMPLETE PARALYSIS: AX 3D GRE T1 + Gd SAG REFORMAT CHECK FOR BONY FRAGMENTS INDICATION FOR IMMEDIATE DECOMPRESSIVE SURGERY OTIC CAPSULE SPARING FRACTURE WITH FACIAL NERVE THICKENING AND ENHANCEMENT. DUE TO HB GRADE 5 PALSY AND THE FINDINGS ON MRI, DECOMPRESSIVE SURGERY WAS PERFORMED MANDIBULO- MANDIBULO- I. MANDIBULO- I. MANDIBULO- II. SKULL BASE / TEMPORAL BONE TRAUMA II. SKULL BASE / TEMPORAL BONE TRAUMA III. THE BEST OF THE REST III. THE BEST OF THE REST MANDIBULO- MANDIBULO- Female, 34-years-old Recent episode of meningitis. Prior history of functional endoscopic sinus surgery (FESS). MENINGO-ENCEFALOCELE THROUGH CRIBRIFORM PLATE DEFECT.
MANDIBULO- MANDIBULO- Male, 25-years-old Anaesthesiologist request CT scan. Clinical information: unable to awake the patient after FESS MANDIBULO- MANDIBULO- Female, 47-years-old Maxillofacial surgeon plans sinus augmentation surgery prior to implant surgery. In the same session, he is also planning to treat the coincident sinusitis The day of the treatment, immediately after surgery, he request an urgent CT scan for right-sided facial swelling and visual loss PERFORATION OF THE POSTERIOR SPHENOID SINUS WALL WITH POSTERIOR COMMUNICANS ARTERY TRANSECTION AND SAH MANDIBULO- TAKE HOME MESSAGES NO LEFORT FRACTURE WITHOUT PTERYGOID PLATE FRACTURE I FLOATING TEETH / II FLOATING MAXILLA / III FLOATING FACE USUALLY MIXTURE OF DIFFERENT TYPES OF FRACTURES MANDIBULA: FRACTURES AT DIFFERENT PLACES ORBITAL FRACTURE: TOTAL PERFORATION RESOLUTION OF THE AFTER ORBITAL FLOOR ORBITAL WITH INTRACONAL FLOOR BLEEDING, RECONSTRUCTION PARTIAL HERNIATION AND OF THE RESORPTION INFERIOR RECTAL OF THE MUSCLE INTRACONAL AS WELL AS BLEEDING. INTRAORBITAL OPTIC FAT NERVE IN THE WAS DEFECT NOT TRANSSECTED NOR DAMAGED MEDIAL / INFERIOR RECTAL MUSCLE ORBITAL APEX INFRAORBITAL NERVE T BONE FRACTURE: OTIC CAPSULE SPARING OR NOT OSSICULAR DISLOCATION MORE FREQUENT THAN FRACTURE
MANDIBULO LO- THANK YOU FOR YOUR ATTENTION