Trauma

Traumatic hemorrhage and rapid expansion of a cervical lymphatic malformation

January 1, 2011     Nishant Bhatt, MD, Helen Perakis, MD, Tammara L. Watts, MD, PhD, and Jack C. Borders, MD
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Aspiration of radiolucent dentures in facial trauma: Case report

December 17, 2010     Jon B. Chadwell, MD, Joshua R. Mitchell, MD, Michael Donnino, MD, Charles Peterson, MD, Paul Guentert, MD, Cliff Arnold, BA, and Mark Walsh, MD
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Abstract

Foreign body aspiration is a serious problem that may lead to complications or even death. People who sustain major maxillofacial trauma can often damage their teeth or oral prostheses, and aspiration can occur. Detection of this type of aspiration can be difficult, especially in elderly people wearing dental appliances, since many dental prostheses are not radiopaque and the aspiration is not always recognized at the time of injury. We report a specific case of extensive maxillofacial trauma from a self-inflicted gunshot wound leading to aspiration of large, radiolucent denture fragments, delayed diagnosis, and complications. The possibility of denture fragment aspiration must always be part of the differential diagnosis in an elderly trauma patient presenting with dyspnea, hypoxia or, eventually, pneumonia. This is especially so when radiologic evaluation does not reveal a foreign body, since much dental prosthesis material is radiolucent. Delayed complications of radiolucent dental prosthesis aspiration could be avoided by the inclusion of some radiopaque material within the acrylic material of the prosthesis.

Botulinum toxin-assisted endoscopic repair of traumatic vocal fold avulsion

August 31, 2010     Rima F. Abraham, MD, Stanley Shapshay, MD, and Lisa Galati, MD
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Abstract

Blunt traumatic laryngeal injury in children often leads to intralaryngeal soft-tissue damage, which can quickly compromise an already small airway. Injuries requiring operative intervention have historically been repaired via open approaches such as thyrotomy and laryngofissure. These approaches carry significant long-term sequelae that can compromise the airway, deglutition, and voice. We describe a safe and effective alternative to open repair that includes the use of a botulinum toxin chemical myotomy to ensure optimal healing. We used this procedure to treat a 13-year-old boy who had experienced a traumatic avulsion of the true vocal folds. Postoperatively, his voice outcome was satisfactory, as evidenced by a marked improvement in his pediatric Voice Handicap Index score. No complication or compromise of the airway or swallowing occurred, and resolution of the botulinum effect was observed by 6 months postoperatively. The endoscopic approach supplemented by botulinum toxin injection avoids scarring and allows for safe postoperative extubation. Compared with open repair, it is associated with a shorter hospital stay and a lower risk of stenosis and fibrosis.

Expect the unexpected: Two cases of penetrating head and neck trauma from Operation Iraqi Freedom

August 31, 2009     CPT Debjeet Sarkar, MD, CPL Andrew Demma; CPT Dean Stulz, PA-C, and LTC Gunther Hsue, MD
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Abstract

The protocol for treating penetrating head and neck trauma in a war zone differs from the standard protocol. Rather than first securing an airway, as is standard in civilian trauma cases, the primary emphasis is on assessing and controlling hemorrhage because it is the leading cause of morbidity and mortality in a battlefield setting. Once that has been addressed, we shift to standard advanced-trauma life-support protocols. We describe two cases we encountered at our combined medical clinic in Western Baghdad-one involving a 4-year old Iraqi child with an ammunition round lodged in her neck and one involving a 38-year-old female U.S. soldier with a round lodged in her right superolateral orbit. Both cases were transferred to combat support hospitals for further treatment after our initial assessment and treatment, and both had successful outcomes.

Distal parotid duct pseudocyst as a result of blunt facial trauma

July 31, 2009     Ashkan Monfared, MD, Justin Ortiz, MD, and Carrie Roller, MD
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Abstract

The sequelae of sharp trauma to the parotid duct, such as sialocele and salivary fistula, are well known. In contrast, complications of blunt trauma to the parotid duct are not as common. A search of the English-language literature revealed 2 cases of parotid pseudocysts caused by blunt trauma. Although no well-known management protocol exists for complications of blunt trauma to the parotid duct, the treatment modalities for sharp trauma complications potentially could be applied. We describe a case of a blunt-trauma-induced distal parotid duct pseudocyst that remained refractory to conservative management, including repeated aspiration and cannulation of the duct. After characterizing and localizing the pseudocyst with sialography and cross-sectional imaging, we performed a surgical repair. This repair involved marsupialization of the parotid duct to the level of the pseudocyst. The edges of the opening of the proximal duct and the pseudocyst were sutured to the oral mucosa, and a small intraoral drain was left in the pseudocyst to prevent collapse and abscess formation. The drain was removed after 5 days, and the patient experienced no further problems during 14 months of follow-up.

Transport of a patient with massive traumatic epistaxis using a cricket helmet and posterior nasal packing

May 31, 2009     Philip V. Alexander, MS and Alka Walters, MS
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Abstract

In developing countries, when patients with traumatic epistaxis cannot be adequately treated at their local medical facility and require further treatment at a distant tertiary care center, it is important that bleeding be controlled before their transport. We describe a patient with a traumatic anterior ethmoidal artery bleed who needed to be taken to a tertiary care center 8 hours away for endoscopic ablation, which was not available at our hospital. The inflated balloon of an 18-Fr Foley catheter attached to the face guard of a cricket helmet was used as a posterior nasal pack. The patient arrived safely and was successfully treated. This case report illustrates that, in an emergency, readily available materials can be used to effect adequate tamponade of nasal bleeding so that a patient can be transferred safely. We believe this is the only such report in the literature.

Ear trauma caused by a yucca plant leaf spine

May 31, 2009     Yoav P. Talmi, MD, FACS, Michael Wolf, MD, Lela Migirov, MD, and Jona Kronenberg, MD
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Abstract

Three uncommon cases of ear trauma caused by a yucca plant leaf spine are presented. One patient presented with tympanic perforation and the second with mixed hearing loss after spontaneous closure. The third patient probably had a perilymphatic fistula with subsequent labyrinthitis and hearing loss. Although the yucca is a ubiquitous plant, to the best of our knowledge, such incidents have not been previously reported.

The role of angiography in managing patients with temporal bone fractures: A retrospective study of 64 cases

April 30, 2009     K. Asif Ahmed, MD, David Allison, MD, Wesley S. Whatley, MD, and Rakesh K. Chandra, MD
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Abstract

We conducted a retrospective study of the utility of angiography in the evaluation of patients with temporal bone fractures. Our study population was made up of 64 patients-58 males and 6 females, aged 14 to 75 years (mean: 35.3)-with a temporal bone fracture who had presented to a level I trauma center over a 1-year period. Records were reviewed and data were obtained on the mechanism of injury; the type of fracture; associated injuries, particularly neurocranial injuries detected on computed tomography (CT) of the head; and any angiographic findings that might have been obtained. The primary outcomes measures were the type of treatment administered (conservative vs. surgical) and mortality. Patients were assigned to 1 of 4 groups according to CT results and angiographic findings, if any: normal CT and no angiogram (group 1; n = 12), abnormal CT and no angiogram (group 2; n = 28), abnormal CT and an abnormal angiogram (group 3; n = 9), and abnormal CT and a normal angiogram (group 4; n = 15). Conservative treatment was administered to all 12 patients in group 1 and to 9 patients (60%) in group 4; surgical treatment was provided to two-thirds of the patients in both group 2 and group 3. Mortality was low in group 1 (n = 0), group 3 (n = 1; 11%), and group 4 (n = 1; 7%), but high in group 2 (n = 10; 36%). In fact, the key finding of this study was that mortality in the group with an abnormal CT and no angiogram (group 2) was significantly higher than mortality in the group with an abnormal CT and an abnormal angiogram (group 3) (p = 0.02), even though the injuries in the 2 groups were similarly severe and their management was similarly aggressive. We conclude that current guidelines for angiography may need to be expanded to include all patients who have CT evidence of neurocranial injury in order to detect those vascular injuries that need aggressive management and thus lower overall mortality.

Depressed anterior table fracture: A minimally invasive method of reduction

January 1, 2009     Derek K. Hewitt, MD, MPH, Troy D. Scheidt, MD, and Karen H. Calhoun, MD
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Abstract

One-third of frontal sinus fractures are isolated to the anterior table. Traditional approaches to the reduction of an isolated anterior table fracture include the coronal incision, the bilateral brow incision, an endoscopic brow lift with an incision either directly over the fracture or in the brow, and delayed repair with a camouflaging implant. We describe a case involving a 14-year-old boy with a depressed anterior table fracture that we successfully treated using a minimally invasive technique requiring only one 2-cm incision.

Middle ear barotrauma with hyperbaric oxygen therapy: Incidence and the predictive value of the nine-step inflation/deflation test and otoscopy

December 1, 2008     Serdar Karahatay, MD, Yavuz Fuat Yilmaz, MD, Hakan Birkent, MD, Hakan Ay, MD, and Bulent Satar, MD
article

Abstract

We conducted a prospective study to determine the incidence of middle ear barotrauma in patients who were undergoing hyperbaric oxygen therapy (HBOT). We also investigated the value of the nine-step inflation/deflation test and otoscopic findings before and immediately after the initial HBOT session in predicting barotrauma in an attempt to establish some criteria for prophylaxis. The study was conducted on 36 ears of 18 adults who had no history of eustachian tube dysfunction. Patients were being treated with HBOT for sudden hearing loss, wound-healing complications, or complications of diabetes. After 7 days of HBOT, barotrauma was seen in 12 of the 18 patients (66.7%) and in 18 of the 36 ears (50.0%). The nine-step inflation/deflation tests, which were performed before and immediately after the initial HBOT session, were not predictive of barotrauma (p = 0.095 before and p = 0.099 after). However, otoscopic findings obtained immediately after the first session of HBOT were predictive of barotrauma, with a sensitivity and specificity of 83 and 100%, respectively. We conclude that patients with even minor positive pathologic findings on otoscopy immediately following HBOT are at increased risk of middle ear barotrauma if HBOT is to be continued without prophylaxis.

Traumatic pseudoaneurysm of the occipital artery: Case report and review of the literature

October 31, 2008     Manish Patel, MD, Hisham Tchelepi, MD, and Dale H. Rice, MD
article

Abstract

Only 3 cases of traumatic pseudoaneurysm of the occipital artery have been reported since 1644. We report a fourth case, which occurred in an 85-year-old woman who experienced a blunt trauma during a fall. The pseudoaneurysm resolved without surgical intervention. We also review the literature on traumatic pseudoaneurysms, as well as true aneurysms, of the external carotid system, with emphasis on current diagnostic and therapeutic options.

Eagle syndrome: Case report and review of the literature

October 31, 2008     Esther Kim, MD, Karla Hansen, MD, and James Frizzi, MD, FACS
article

Abstract

Eagle syndrome, which is an uncommon sequela of elongation of the styloid process, can manifest as pain in the anterolateral neck, often with referred pain to the ear. In most cases, the elongation is an acquired condition, often occurring as a result of a traumatic incident, including tonsillectomy. We describe the case of a 57-year-old man who experienced unremitting right neck pain for several years following an accidental fall. A multidisciplinary investigation identified an elongated styloid process. Surgical shortening of the structure provided definitive relief of the patient's symptoms. We review the anatomy of the peristyloid structures and discuss the etiology, diagnosis, and treatment of Eagle syndrome.

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