Download A Shattered Face - Lieberman`s eRadiology

May 2010
A Shattered Face:
Radiologic and Surgical Reconstruction
of Complex Craniofacial Trauma
Kapil Verma, Harvard Medical School Year IV
Gillian Lieberman, MD
Beth Israel Deaconess Medical Center
Harvard Medical School
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Background:
Epidemiology of craniofacial trauma
•
Approximately 50% of the 12 million annual traumatic wounds
treated in emergency rooms across the United States involve the
head and neck
•
Common causes of craniofacial trauma include:
- Motor vehicle accidents (community setting)
- Assault (urban setting)
- Sports injuries and falls
- Domestic violence
•
Among level-1 trauma centers, facial trauma is managed by:
- Plastic surgeons (40%)
- Oral and maxillofacial surgeons (36%)
- Otolaryngologists/head and neck surgeons (23%)
- General surgery and Oculoplastics (~0.5%)
Singer, Hollander, Quinn
Aksoy, Unlu, Sensoz
Bagheri et al
Holmes
Background:
Why recognition and management of craniofacial
trauma is crucial
•
The face contains crucial specialized systems needed to see,
hear, smell, breathe, eat, and speak
•
Vital structures within the head and neck are intimately
associated
•
Several facial injuries may be life threatening:
- Hemorrhage
- Airway obstruction
- Aspiration
•
The psychological impact of facial disfigurement can be
devastating
Manson et al
Lee et al
Background:
Clinical exam findings in the recognition of
craniofacial trauma
•
•
•
•
•
•
•
Facial asymmetry
Pain upon palpation
Facial instability
Cortical step-offs
Periorbital edema
Periorbital crepitus
Infraorbital
numbness
Epistaxis
Epiphora
Exopthalmus
Enopthalmus
Telecanthus
Orbital muscle/nerve
entrapment
• Many more …
•
•
•
•
•
•
Manson et al
Background:
Limitations of the clinical exam in the recognition of
craniofacial trauma
Clinical evaluation of the facial skeleton in
trauma patients is difficult:
- Facial features are often obscured and
distorted by endotracheal and gastric tubes
and tapes that hold them in place. Thus,
evaluation of facial instability is difficult
- Response to painful stimuli is blunted. Thus,
evaluation of localized pain secondary to
fractures is difficult
Rehm, Rhos
Background:
The crucial role of radiologic imaging in the
recognition of craniofacial trauma
• Up to 60% of facial fractures may be missed
clinically (lack of step-offs, instability, orbital
entrapment, telecanthus, etc) and are later detected
by CT
•
Of those 60% of clinically unsuspected facial
fractures later detected on CT, approximately 50%
require subsequent surgical repair
• As a result, though plastic surgeons and
maxillofacial surgeons primarily manage
craniofacial trauma, the radiologist plays a crucial
role in diagnosis to guide management
Rehm, Rhos
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Normal craniofacial skeletal anatomy:
The skull consists of cranial and facial bones
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Components of both cranial and facial bones form the
orbit - colloquially known as the ‘eye socket’
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Lateral view of the 22 bones of the skull,
8 cranial bones and 14 facial bones
8 cranial bones:
1
2
1
2
1
x
x
x
x
x
Frontal
Parietals
Sphenoid
Temporals
Ethmoid
14 facial bones
2
2
1
2
2
2
2
1 x Occipital
x
x
x
x
x
x
x
Lacrimals
Inferior Nasal Conchae
Vomer
Nasals
Zygomatics
Palatines
Maxillae
1 x Mandible
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Anterior view of the facial bones and orbit
7 orbital bones
Frontal
Sphenoid
Ethmoid
Palatine
Lacrimal
Zygomatic
Maxillary
Cranial
Facial
14 facial bones
2
2
1
2
2
2
2
x
x
x
x
x
x
x
Lacrimals
Nasals
Vomer
Inferior Nasal Conchae
Maxillae
Palatines
Zygomatics
1 x Mandible
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Skeletal anatomy of the orbit
7 orbital bones
Frontal
Sphenoid
Cranial
Ethmoid
Palatine
Lacrimal
Zygomatic
Maxillary
Facial
http://www.ophthobook.com/wp-content/uploads/2007/12/an-orbitbone.jpg
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Anatomy of the mandible
Coronoid process
Condylar process
Ramus
http://www.face-and-emotion.com/dataface/anatomy/facialbones.jsp
Angle
Body
Symphysis
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Shattered Anatomy: Intro to Patient AA
History
• 37M unhelmeted bicycle rider struck by a car, propelled
head first through windshield
• Widely opened multiple cranial and facial fractures with
visible brain material, otherwise (remarkably) no other
no traumatic injury to the chest, abdomen, or pelvis
•
Intubation initially difficult secondary to multiple facial
fractures
• Unable to immediately assess for clinical signs of orbital
entrapment secondary to patient’s waning mental status
Shattered Anatomy: Intro to Patient AA
Initial 3D Facial CT Reconstruction Anterior View
NORMAL
OUR PATIENT, AA
Anterior 3D-reformatted CT reconstructions of the face
Normal patient on the left. Our patient AA on the right
GE Vitrea 3D Workstation, MGH
Shattered Anatomy: Intro to Patient AA
Initial 3D Facial CT Reconstruction Oblique view
NORMAL
OUR PATIENT, AA
Oblique 3D-reformatted CT reconstructions of the face
Normal patient on the left. Our patient AA on the right.
GE Vitrea 3D Workstation, MGH
Shattered Anatomy: Intro to Patient AA
List of craniofacial injuries (to be revisited)
OUR PATIENT, AA
Severely comminuted, complex
frontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort II fractures
Anterior 3D-reformatted CT reconstruction
of the face
Comminuted fractures of the
ethmoid and sphenoid sinuses,
nasal bone fractures
GE Vitrea 3D Workstation, MGH
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Menu of radiologic tests:
Traditional facial radiograph series- outdated in the
evaluation of facial trauma
•
Traditional facial radiographic series
include those such as the ‘Waters
view,’ ‘Caldwell view,’ ‘Towne view’
and submentovertex view
•
Such views are outdated in
evaluation of facial trauma:
difficulty of interpretation
amongst non-radiologist
physicians
inability to assess soft tissues
in detail
advent of CT and 3D CT
reformatting
http://www.ispub.com/journal/the_internet_journal_of_otorhi
nolaryngology/volume_5_number_2_21/article/inter_observ
er_and_intra_observer_variability_in_the_assessment_of_t
he_paranasal_sinuses_radiographs.html
Chen, Ng, Whaites
Menu of radiologic tests:
Facial Multidetector CT - the imaging gold standard
• Facial Multidetector CT without contrast with axial
and coronal sections is the gold standard in the
evaluation of facial trauma
– Fast
– Bone windows may evaluate for fractures
– Soft tissue windows may simultaneously evaluate for
secondary soft tissue swelling (including extra-ocular
muscles, nerves, and globe) and hematomas
– Coronal sections are superior to radiographs in
showing orbital floor fractures
– Subsequent 3D CT reformatting is possible
Tanrikulu, Erol
Menu of radiologic tests:
CT with 3D reformatting - Background
• Contiguous 2D CT slices are obtained via
normal CT protocol
• These series of tomographs are analyzed by
a 3D software program
• The computer essentially uses one of two
rendered techniques to obtain a 3D image:
1- Threshold/Surface Rendering
2- Volume Rendering
Kung, Fung
Menu of radiologic tests:
CT with 3D reformatting – Surface rendering and
volume rendering
• Principle behind threshold/surface rendering is based on
the Hounsfield scale (quantitative scale for radiodensity in
CT using Hounsfield Units = HU)
-1000 HU: Air
-100Æ-30 HU: Fat
0 HU: Water
+30Æ+100 HU: Soft tissue
+1000 HU: Cortical Bone
• Can select CT attenuation value of +150 HU as threshold,
and thus all soft tissues (below +150 HU) excluded in final
3D CT image, and only bone (and other structures with
HU > +150) included
• Volume rendering performs a similar algorithm using
summation
Kung, Fung
Menu of radiologic tests:
CT with 3D reformatting - Conceptually simplified
Combine with
coronal sections
Apply rendering
algorithms
using HU
thresholds
to subtract
soft tissues
Axial CT sections obtained from PACS BIDMC; stacked graphic created independently
3D CT Face reconstruction image obtained from GE Vitrea 3D Workstation, MGH
Menu of radiologic tests:
CT with 3D reformatting - useful for the surgeon
• Surgeons generally ‘think in 3D’ vs.
radiologists with specialized training in
3D interpretation of 2D imaging
• 3D reformatting may aid in pre-surgical
planning
• 3D reformatting may aid in the design of
custom facial prosthetics
Reuben, Watt-Smith, Dobson, et al
Alder, Deahl, Matteson
Menu of radiologic tests:
Panorex
• 2D panoramic x-ray (radiograph) of the upper and
lower teeth and mandible
• Displays the mandible as a flat structure
•
Combined with CT, picks up virtually all fractures
of the mandible
• When used alone, often misses parasymphysial
fractures of the mandible
Romeo, Pinto, Cappabianca, et al
Menu of radiologic tests:
Panorex – may miss mandibular fractures if used alone
-This patient was initially noted to only have 1 left nondisplaced
fracture at the junction of the mandibular ramus and condylar
process from this Panorex
Panorex film of the mandible, upper and lower teeth
AGFA, MGH
Menu of radiologic tests:
Panorex – may miss mandibular fractures if used alone
-This patient was initially noted to only have 1 left nondisplaced
fracture at the junction of the mandibular ramus and condylar
process from this Panorex
Panorex film of the mandible, upper and lower teeth
AGFA, MGH
Menu of radiologic tests:
Panorex – should be used in conjunction with CT for
the evaluation of mandibular fractures
- On subsequent CT, however, in addition to known left mandibular
fracture, she was found to have 2 additional mandibular fractures: a
right condylar process fracture, and a parasymphysial fracture
Coronal C- CT sections through mandible
AGFA, MGH
Menu of radiologic tests:
Panorex – should be used in conjunction with CT for
the evaluation of mandibular fractures
- On re-evaluation of original Panorex, the 2 additional fractures seen on
CT became apparent, though still difficult to assess on Panorex alone
Panorex film of the mandible, upper and lower teeth
AGFA, MGH
The patient subsequently had arch bar placement and
wire fixation of her maxillary and mandibular teeth
Panorex film of the mandible, upper and lower teeth; post arch bar placement and wire fixation of upper
and lower teeth
AGFA, MGH
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Patient AA revisited:
Frontal bone fractures
OUR PATIENT, AA
Severely comminuted, complex
frontal bone fractures
Anterior 3D-reformatted CT reconstruction
of the face
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Frontal bone fractures on CT
Axial C- CT through the level of the frontal bone; bone window
AGFA, MGH
Patient AA revisited:
Frontal bone fractures on CT, Findings
Axial C- CT through the level of the frontal bone; bone window
•
Numerous severely
comminuted fractures of
the frontal bone
•
Low attenuation areas of
subcutaneous emphysema
•
High attenuation foreign
objects, likely leadcontaining glass
fragments (as patient was
projected head first
through windshield)
AGFA, MGH
Patient AA revisited:
Orbital rim, wall, and floor fractures
OUR PATIENT, AA
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Anterior 3D-reformatted CT reconstruction
of the face
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Orbital fractures on CT
Coronal C- CT through the level of the orbits; bone window
Sagittal C- CT through the level of left orbit; bone window
AGFA, MGH
Patient AA revisited
Orbital fractures on CT, Findings
•
Non-orbital fracture seen: Depressed
skull fragment of frontal bone (on soft
tissue window seen to cause cerebral
edema, necessitating subsequent
craniectomies and ventriculostomy)
Coronal C- CT through the level of the orbits; bone window
•
Complex displaced fracture of the right
superior lateral orbital rim
•
Non-displaced fracture of the left lateral
orbital wall
•
Bilateral comminuted orbital floor
fractures
•
Depressed orbital floor fracture on the
right
AGFA, MGH
Sagittal C- CT through the level of left orbit; bone window
Patient AA revisited:
Orbital injury on CT, soft tissue window
Coronal C- CT through the level of the orbits; soft tissue window
AGFA, MGH
Patient AA revisited:
Orbital injury on CT, soft tissue window findings
*
*
Coronal C- CT through the level of the orbits; soft tissue window
•
Extra-ocular muscles within
orbit
•
Downward herniation of
perioribital fat (HU: -60)
into right maxillary sinus
•
Blood in bilateral maxillary
sinuses
•
No evidence of optic nerve
or extraocular muscle
entrapment seen on
subsequent clinic exam
(PERRL; negative forced
duction test)
AGFA, MGH
Patient AA revisited:
Bilateral LeFort II fractures
OUR PATIENT, AA
Bilateral LeFort II fractures
Anterior 3D-reformatted CT reconstruction
of the face
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Bilateral LeFort II fractures on CT
Axial C- CT through the level of sphenoid; bone window
Coronal C- CT through the level of the maxilla; bone window
AGFA, MGH
Patient AA revisited:
Bilateral LeFort II fractures on CT,
Findings
• Bilateral fractures of the
pterygoid processes of
the sphenoid (defines all
LeFort maxillary
fractures)
Axial C- CT through the level of sphenoid
• Bilateral medial orbital
wall fractures resulting
in pyramidal pattern of
the LeFort II fracture
AGFA, MGH
Coronal C- CT through the level of the maxilla
Patient AA revisited:
Comminuted fractures of the ethmoid and sphenoid
sinuses, nasal bone fractures
OUR PATIENT, AA
Comminuted fractures of the
ethmoid and sphenoid sinuses,
nasal bone fractures
Anterior 3D-reformatted CT reconstruction
of the face
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Comminuted fractures of the ethmoid and sphenoid
sinuses, nasal bone fractures on CT
Axial C- CT through the level of the ethmoid and sphenoid sinuses
Bone window
Axial C- CT through the level of the nasal bones
Bone window
Patient AA revisited:
Comminuted fractures of the ethmoid and sphenoid
sinuses, nasal bone fractures on CT, Findings (with
blood in both sinuses)
*
*
Axial C- CT through the level of the ethmoid and sphenoid sinuses
Bone window
Axial C- CT through the level of the nasal bones
Bone window
AGFA, MGH
Patient AA revisited:
Summary of all fractures
OUR PATIENT, AA
Severely comminuted, complex
frontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort II fractures
Anterior 3D-reformatted CT reconstruction
of the face
Comminuted fractures of the
ethmoid and sphenoid sinuses,
nasal bone fractures
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Follow-up
OUR PATIENT, AA POST-OP
• Due to elevated
intracranial
pressure, underwent
bifrontal
craniectomies
• Left ventriculostomy
tube was placed
• ORIF of frontal sinus
fracture
Anterior 3D-reformatted CT reconstruction of the face
post bifrontal craniectomies with ventriculostomy tube
placement, and ORIF of comminuted frontal sinus fractures
GE Vitrea 3D Workstation, MGH
Patient AA revisited:
Post craniectomies and ventriculostomy tube imaging
Oblique 3D-reformatted CT reconstruction of the face
post bifrontal craniectomies with ventriculostomy tube
placement
Sagittal C- CT Head post bifrontal craniectomies with
ventriculostomy tube placement
GE Vitrea 3D Workstation, MGH
AGFA, MGH
Patient AA revisited:
List of subsequent craniofacial reconstructive
procedures
• Bilateral arch bar placement with intermaxillary
fixation
• ORIF of right zygomaticofrontal suture
• ORIF of right orbital floor fracture with
reconstruction of the floor with alloplastic implant
• ORIF of bilateral LeFort II fractures
• Closed reduction of the nasal fractures
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Agenda
`
Background
`
Normal craniofacial skeletal anatomy
`
Shattered anatomy: Intro to patient AA
`
Menu of radiologic tests
`
Patient AA revisited
`
Conclusions
Conclusions
•
Craniofacial trauma can be devastating if not acutely
recognized and managed
•
The recognition of craniofacial trauma depends heavily on
radiologic imaging since the clinical exam is unreliable (60%
of facial fractures are missed clinically)
•
Facial CT is the gold standard in the evaluation of facial
trauma: facial radiographs are outdated, except for Panorex
which still has utility when used in conjunction with CT in the
evaluation of mandibular fractures
•
3D CT reconstructions provide useful information in surgical
planning
Acknowledgments
•
•
•
•
•
•
•
Gillian Lieberman, MD
Yoon S. Chun, MD
Hillary Kelly, MD
Gregory Czuczman, MD
David Li, MD
Maria Levantakis
Linda Burke
References
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2- Bagheri SC, Dimassi M, Shahriari A, et al. Facial Trauma Coverage Among Level-1 Trauma Centers of the
United States. J Oral Maxillofac Surg. 2008; 66(5):963-7
3- Holmes S. Facial Trauma – who should provide care? Br J Oral Maxillofac Surg. 2009; 47:179-81
4- Aksoy E, Unlu E, Sensoz O. A retrospective study on epidemiology and treatment of maxillofacial
fractures. J Craniofac Surg. 2002; 13(6):772-5
5- Manson P, Clark N, Robertson B, Crawly W. Comprehensive management of pan facial fractures. J
Craniomaxillofac Trauma. 1995; 11:43-56
6- Lee SS, Huang SH, Wu SH, et al. A Review of Intraoperative Airway Management for Midface Facial Bone
Fracture Patients. Ann Plast Surg. 2009;63(2):162-166
7- Rehm CG, Ross SE. Diagnosis of Unsuspected Facial Fractures on Routine Head Computerized
Tomographic Scans in the Unconscious Multiply Injured Patient. J Oral Maxillofac
Surg.1995;53:522-54
8- Chen TW, Ng SY, Whaites EJ. Interpretation of skull radiographs for facial fractures by medical staff
working in UK emergency departments: a pilot study. Dentomaxillofac Radiol. 2003;32(3):166-72
9- Tanrikulu R and Erol B. Comparison of computed tomography with conventional radiography for midfacial
fractures. Dentomaxillofac Rad. 2001; 30:141-146
10- Reuben AD, Watt-Smith R, Dobson D, et al. A comparative study of evaluation of radiographs, CT and 3D
reformatted CT in facial trauma: what is the role of 3D? Br J Radiol 2005; 78:198–201
11- Alder ME, Deahl ST, Matteson SR. Clinical Usefulness of Two-Dimensional Reformatted and ThreeDimensionally Rendered Computerized Tomographic Images: Literature Review and a Survey of
Surgeons' Opinions. J Oral Maxillofac Surg. 1995; 53(4):375-86
12- Romeo A, Pinto A, Cappabianca S, et al. Role of multidetector row computed tomography in the
management of mandible traumatic lesions. Semin Ultrasound CT MRI. 2009; 30:174-180
13- Wolfe SA, Ghurani R, Podda S, et al. An examination of posttraumatic, postsurgical orbital deformities:
conclusions drawn for improvement of primary treatment. Plast Reconst Surg. 2008; 122(6):1874